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Issue 4 (2017) – Supplement 1


Special Issue from the Lisbon Stroke Summit

This supplemental issue comprises the abstracts from the Lisbon Stroke Summit 2017, Lisbon, Portugal. 7–8 April 2017.

Guest editors:
Ana Paiva Nunes
Elsa Azevedo

Issue Nr:

4

|    Issue date: 2017-04-05

Debate


Challenging clinical case—unstable carotid plaque - read full article

By: Eduardo Freitas, Célia Machado, José Amorim, João Pinho, Jaime Rocha, and Carla Ferreira

We present a 79-year-old man with a previous history of hypertension, dyslipidemia and ischemic stroke of the left middle cerebral artery caused by severe atherosclerotic stenosis of the left internal carotid artery (treated with carotid artery stenting) in 2011. He was medicated with clopidogrel 75mg/day, ramipril 2.5mg/day and atorvastatin 20mg/day. He was admitted for a left-hand motor deficit after he woke up. Vital signs were normal and there was a mild motor deficit of the left upper limb, with apraxia of the left hand. Electrocardiography showed sinus rhythm, and there were no signs of acute ischemia or hemorrhage in brain CT. Carotid ultrasound showed a normal position of the left stent with no residual stenosis and, additionally, an irregular hypoechoic atherosclerotic plaque in the proximal right internal carotid artery without significant stenosis. He was treated with a loading dose of acetylsalicylic acid and maintained double antiplatelet therapy and atorvastatin 80mg/day. On the third day after admission, the left motor deficit worsened. The brain MRI revealed multiple acute hyperintense ischemic lesions in the right hemisphere (cortical and subcortical) with varying intensities suggesting different timings of the ischemic lesions. At this point we would like to discuss with the experts the best management in this case, namely among the following options: maintain double antiplatelet therapy and close monitoring; start anticoagulation; or proceed to endovascular or surgical treatment of the unstable plaque.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):D1

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Debate


Acute ischemic stroke and unruptured aneurysm: what now? - read full article

By: Ary de Sousa, Patrícia Ferreira, Sofia Galego, Isabel Fragata, João Reis, and Ana Paiva Nunes

Introduction: Unruptured cerebral aneurysms are currently considered a contraindication to thrombolytic therapy for acute ischemic stroke, due to its theoretical increase in the risk of haemorrhage from aneurysm rupture. 
Results: A 51-year-old female presented at the Emergency Department with a sudden language change. Past history was relevant for dyslipidaemia treated with simvastatin and regular consumption of pharmacologic preparations intended for weight loss. The initial observation revealed mild aphasia, flattened right nasolabial fold and right mild hemiparesis with mild sensory loss (NIHSS 5). Brain CT scan was normal and CT angiography revealed a probable occlusion of the Sylvian branch of the left middle cerebral artery (M3 segment) and a saccular aneurysm of the anterior communicating artery with approximately 8mm. Given the minor and regressing clinical picture and the presence of an aneurysmal formation, it was decided not to treat with thrombolytic therapy. At the Stroke Unit, a brain MRI revealed multiple acute ischemic lesions in several arterial territories suggestive of an embolic source. Her EKG monitoring remained always in sinus rhythm. Transthoracic echocardiogram revealed a slightly dilated left atrium and mild-to-moderate aortic insufficiency. Transesophageal echocardiogram showed no additional relevant changes. Extracranial and transcranial ultrasounds were normal. At discharge, she maintained some degree of anomic pauses and paraphasia with mild slurring of speech, mild flattened right nasolabial fold and loss of right-hand fine motor skills with mild sensory loss of the right lower limb (NIHSS 4). The aetiology of these changes remains unknown. She was released with combined clopidogrel-aspirin and a plan for readmission 3 weeks later for aneurysm endovascular treatment. 
Conclusion: This case illustrates the difficulty in deciding stroke acute-phase treatment when aneurysms with more than 5mm are identified, due to the uncertainty on intravenous alteplase safety in the treatment of these patients.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):D2

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Debate


A double dilemma in one patient - read full article

By: Catarina Perry da Câmara, Carolina Pinheiro, Marcos Veiga, Teresa Morais, Mariana Diogo, Sofia Galego, Isabel Fragata, Patrícia Ferreira, Ana Paiva Nunes, and João Reis

Background: Dissection of the carotid artery can cause stenosis and occlusion. In certain cases, acute phase carotid stenting is an option. 
Methods: We present a case of stent placement in the acute phase of bilateral dissection of internal carotid artery (ICA). 
Results: We report a case of a 46-year-old woman, with no past relevant history. Her only medication was oral contraception. She presented with headache, vertigo and bilateral leg paresis with left predominance. At the emergency room (ER), no neurological focal signs were detected and she was discharged. In the following day, she returned to the ER with the same symptoms. This time she had left hemianopia, central facial palsy (LCFP), dysarthria and left hemiplegia (NIHSS 16). CT revealed an ischemic lesion on the right middle cerebral artery (rMCA) territory with occlusion of the right ICA and stenosis of the left ICA, with no repercussion on the transcranial Doppler (TCD). Three days later, TCD showed low blood flow velocity in the left MCA and anterior cerebral artery (ACA), with collateral compensation by the posterior circulation, suggesting a distal ICA lesion. At that time, the patient underwent digital subtraction angiography, showing an irregular stenosis of nearly 80, with cervical aneurysmatic dilatation of the left ICA, and a delay in distal perfusion. A carotid stent was placed with satisfactory reperfusion. The neurosonological study was repeated, revealing an occlusion of the stent and the patient was submitted to mechanical thrombectomy. The patient’s age and angiographic features suggested bilateral carotid dissection with rICA occlusion and left ICA stenosis. The patient was discharged with NIHSS of 12. 
Conclusion: Acute phase carotid stenting is not consensual, but what should we do when facing contralateral occlusion?

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):D3

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Debate


Acute carotid artery stenting in symptomatic high-grade cervical carotid artery stenosis: is it a valid option? - read full article

By: Ary de Sousa, Patrícia Ferreira, Sofia Galego, Isabel Fragata, Ana Paiva Nunes, and João Reis

Introduction: The safety and efficacy of emergency carotid artery stenting (CAS) for patients with acute ischemic stroke resulting from internal carotid artery (ICA) stenosis are not established. 
Results: A 76-year-old male presented to his family doctor complaints of nausea and vomiting since the previous day and left hemiparesis with a 3-hour symptom onset. His previous medical history was positive for hypertension, ischemic heart disease, dyslipidaemia, alcohol abuse, past smoking and sleep apnoea. He was transported to our institution after pre-hospital Stroke Code activation. Initial evaluation revealed flattened left nasolabial fold, left arm pronator drift and mild sensory loss in his left arm (NIHSS 4). According to the patient, the neurological deficits were improving. Brain CT scan was unremarkable and CT angiography revealed bilateral diffuse atherosclerosis with moderate-to-severe stenosing plaques at the bilateral carotid bifurcation. Given the minor and regressing clinical picture, it was decided not to treat with thrombolytic therapy. Brain MRI showed multiple hyperintensities on DWI in the right middle cerebral artery (MCA) territory involving the cortex, with significant DWI-FLAIR mismatch. Extracranial ultrasound (US) confirmed severe proximal bilateral ICA stenosis, with hemodynamic repercussion in the right ophthalmic artery. Transcranial US revealed microembolic signals in the right MCA. Given the active embolic source, he was started on clopidogrel-aspirin combined therapy and a single dose of abciximab for CAS. The patient was submitted to a conventional cerebral angiography on the following day, and bilateral CAS was performed, followed by mechanical angioplasty with intra-stent balloon. Follow-up Doppler-US examination confirmed stent patency. The patient was discharged with mild neurological improvement (NIHSS 3) and maintained under clopidogrel-aspirin combined therapy until reassessment in an outpatient setting. 
Conclusion: This case illustrates that, although carotid stenting is not recommended for the acute phase treatment of symptomatic stenosis, in selected patients it can be a valid treatment option.

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Debate


48th hour dilemma - read full article

By: Rita Prayce, Patrícia Ferreira, Sofia Galego, Isabel Fragata, João Reis, Ana Paiva Nunes, and João Reis

A 58-year-old woman with history of non-treated hypertension presented sudden-onset right side hemiparesis, dysarthria and facial asymmetry. The Stroke Code was activated. Upon admission at the emergency department she was alert, oriented, with a left gaze palsy, normal eye field, subtle horizontal rotatory nystagmus to the left, right hemiplegia and ipsilateral hypoesthesia (NIHSS: 12). The Brain computed tomography (CT) revealed no acute lesions. CT angiography showed basilar artery megadolichoectasia. Treatment with alteplase was promptly initiated, and she was admitted in the Stroke Unit. Close clinical monitoring showed stable neurological deficits in the first 24 hours and the control brain magnetic resonance imaging scan (MRI) exhibited acute left paramedial pons ischemic infarct. Antiplatelet treatment was started. On the second day, neurological deterioration was noted: ophthalmoparesis with right side one-and-a-half syndrome and left limb dysmetria. A new MRI brain scan showed expansion of the ischemic lesion, encompassing the pons and the mesencephalon bilaterally. CT angiography revealed the presence of a nonocclusive endoluminal thrombus. The patient was started on non-fractioned heparin infusion for 48 hours, and then switched to fractioned heparin after CT scan with no bleeding. A control CT angiography revealed reduction of thrombus size. The neurologic deficits stabilized. Slight improvement of the ophthalmoparesis was noted. Conclusion: Would a complementary endovascular approach have an additional benefit 48 hours after symptom onset?

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):D5

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Debate


Severe stenosis of both ICA and basilar artery, in a patient with acute symptoms of different territories—how to manage - read full article

By: Mariana Baptista, Patrícia Ferreira, Isabel Fragata, Sofia Galego, Jaime Pamplona, Ana Paiva Nunes, and João Reis

Clinical Case: A previously independent 77-year-old man, with history of ischemic cardiac disease, hypertension, diabetes and smoking and drinking habits, was recently hospitalized for transient episodes of pre-syncope, dysphagia and left hemiparesis. MRI showed acute ischemic lesions in the territory of the left middle cerebral artery (MCA). The CT-angiography revealed bilateral severe internal carotid artery (ICA) stenosis, stenosis of the M1 segment of the right MCA and V4 segments of both vertebral arteries (VA) and also pre-occlusive stenosis of the basilar artery (BA). Double anti-platelet therapy was initiated and bilateral carotid stents were placed. At discharge, the patient was asymptomatic but returned 4 days later for fluctuating right brachial paresis, four limbs dysmetria and horizontal-rotational nystagmus. Doppler studies confirmed severe stenosis of the BA, with both carotid stents patent. Hypoperfusion of the vertebrobasilar territory was admitted and after multidisciplinary discussion, mechanical angioplasty and stenting of the BA was performed. However, because of further clinical worsening, MRI was made and revealed multiple acute ischemic lesions of the anterior left territory and posterior territory, with occlusion of the left ICA stent and BA, with all intracranial circulation dependent on anastomosis from the right ICA. The patient was clinically stable and was maintained on aspirin and ticagrelor. 
Conclusions: This case raises several important questions: indications for endovascular therapy in multiple stenosis/occlusions, timing of treatment in multiple stenosis and the ideal double anti-platelet scheme.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):D6

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Debate


Early recurrent stroke: reset clock and give RT-PA or directly to thrombectomy? - read full article

By: Fernando Rocha Correia, Margarida Viana, Cristina Correia, Luís Flores, João Coimbra, Cláudia Matos, Teresa Mendonça, Goreti Moreira, Guilherme Gama, and Jorge Almeida

Introduction: It is established that patients who are eligible for intravenous rt-PA therapy should be treated even if endovascular therapy is considered. However, there are situations in which thrombectomy could be directly performed. 
Case: 69-year-old male patient with hypertension and pernicious anemia. He had sudden right arm paresis. Four hours later, at the hospital, the neurological examination was unremarkable. At admission, he was hypertensive (191/94 mmHg) but, otherwise, had normal vital signs.  Analytical study, electrocardiogram and brain CT were normal and he was admitted for transient ischemic attack(TIA) study. The next day, after being asymptomatic for 22 hours, he developed right central facial and limb paresis, scoring 10 in NIHSS. Repeated brain CT and CT-angiography (CTA) showed no early ischemic signs, a left internal cervical carotid (ICA) occlusion and tandem thrombus at the terminal intracranial carotid. Intravenous rtPA was given and he was selected tomechanical thrombectomy. Before the procedure, 2h30 after symptom onset, NIHSS was 5 and a new CT and CTA were performed, showing resolution of the terminal ICA occlusion, left parietal subarachnoid blood and a deep hemorrhagic focus. Thrombectomy was held-up and he returned to stroke unit. He had progression of deficits scoring 20 over the following 72 hours. Ultrasound showed the same left ICA occlusion with patent intracranial main vessels. No other etiology was advanced after study. 
Conclusion: The authors question the need of CTA in TIA’s with presumable cortical symptoms and if, in this particular case, thrombolysis was not beneficial but even detrimental to patient evolution, making impossible to perform thrombectomy.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):D7

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Debate


Should we do it again? - read full article

By: Luís Fontão, Sofia Galego, Patrícia Ferreira, Isabel Fragata, Ana Paiva Nunes, and João Reis

Clinical Case: A 46-year-old female, with history of iron deficiency anemia due to hiatal hernia, is taken to the emergency department with symptoms of speech disturbance and right-sided paresis. Stroke protocol was activated. Neurologic examination showed global aphasia, left oculocephalic forced deviation, right-sided hemiparesis and hemihypoesthesia – NIHSS 23. A brain CT showed loss of grey-white matter differentiation at the left lenticular nucleus (ASPECTS 9). Prompt treatment with alteplase (0.9mg/kg) was initiated, 205 minutes after the onset of symptoms. CT angiography showed a terminal left internal carotid artery (ICA) and proximal (M1) middle cerebral artery (MCA) occlusion and urgent mechanical thrombectomy was performed with TICI 2a reperfusion of the left carotid circulation. The patient was subsequently admitted to the stroke unit. Close clinical monitoring showed no neurologic improvement at 24 hours. At this point, a control brain CT showed left basal ganglia infarct, as well as hyperdense left middle cerebral artery and a carotid/transcranial doppler ultrasound (TCD) revealed persistence of the left ICA thrombus, with no significant hemodynamic effect, as well as high resistance and turbulent flow through the M1-M2 segment of the left MCA. The patient remained neurologically stable (NIHSS 18). On the fourth day, a worsened TCD pattern of the proximal MCA prompted an urgent brain CT angiogram, which confirmed a distal left MCA reocclusion and persistence of left ICA thrombus. Despite not having neurological deterioration, after multidisciplinary decision, the patient underwent DSA and mechanical thrombectomy, successfully removing the internal carotid thrombus but incapable of distal MCA reperfusion. No intracranial hemorrhage or neurological deterioration was noted and NIHSS at discharge was 19. Secondary prevention with single anti-platelet and statin therapy was adopted. 
Conclusion: Should this patient have been submitted to a late reperfusion, after ischemic stroke and reocclusion, considering there was no neurologic deterioration?

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):D8

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Poster


A hole in the heart - read full article

By: Teresa Salero, Sérgio Menezes Pina, Sofia Amálio, Joana Pestana, Ana Paula Fidalgo, and Ana Lopes

Background: Up to 10-40% of all acute ischemic strokes have no obvious underlying cause, being defined as cryptogenic strokes. Patent Foramen Ovale (PFO) is found in nearly 25% of general population and its prevalence among cryptogenic stroke population accounts for 40-50%. 
Case Presentation: A 42-year-old right-handed fisherman, previously Rankin 0, was referred to the Emergency Department with aphasia and right hemiplegia for one-hour. Patient was alcoholic but denied head trauma. He had been immobilized during the previous week due to a patellar dislocation. Physical, cardiologic and neurologic examinations were normal, except for the motor aphasia and right hemiplegia. Cranial computed tomography and angiotomography showed no abnormalities. He underwent fibrinolytic treatment with almost full recovery from previous focal lesions. The magnetic resonance imaging of the brain showed signs of acute (<6h) infarcts along the left middle cerebral artery territory. Laboratory tests included normal complete blood count and routine blood chemistries, serology, autoimmunity and thyroid stimulating hormone. Electrocardiogram showed normal sinus rhythm. Carotid and vertebral Doppler scans, as well as the transthoracic echocardiography, were normal. Without any apparent cause, it was requested a second transthoracic echocardiography, which revealed the presence of the PFO during Valsalva maneuver and discrete right atrium enlargement. The patient was discharged anticoagulated and referred to a Cardiology consult to discuss treatment options. 
Conclusions: PFO should be investigated especially among patients without any other obvious cause for stroke. However, larger studies need to be performed in order to support the correlation between interatrial septal abnormalities and ischemic stroke in young adults.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P1

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Poster


Delayed thrombectomy in acute vertebrobasilar occlusion—case report - read full article

By: Márcia Pacheco, Gil Nunes, Jaime Pamplona, Socorro Piñeiro, Denise Lopes, Ana Pidal, Sónia Costa, Vânia Almeida, Cândida Barroso, and Alexandre Amaral-Silva

Acute basilar thrombosis is associated with poor prognosis. Thrombolysis and thrombectomy may reduce mortality and disability. Some studies suggest that the time window for revascularization is probably longer that in anterior circulation strokes. Case description: A 73-year-old female presented to the Emergency Department complaining of 2 transient episodes of dysarthria. At admission, the only positive finding was mild gait ataxia. Brain computed tomography (CT) documented acute infarcts at the right occipital pole and posterior cerebellar area. Transcranial duplex scan showed mild stenosis (<50%) of the left vertebrobasilar (VB) junction. During the first 24h after admission, progressive neurological deterioration occurred. CT angiography documented left VB junction and proximal basilar segment occlusion with retrograde filling of the distal segment. Cerebral magnetic resonance showed DWI+/FLAIR+ right cerebral peduncle, occipital parasagital, paramedian pontic and cerebellar hemispheric acute ischemic lesions. The patient was somnolent, with dysarthria and left hemiplegia - NIHSS=12. Considering the clinical-imaging mismatch, she was referred to the interventional neuroradiology department at a Comprehensive Stroke Center. Complete recanalization was achieved 31h after hospital admission (19h after clinical deterioration). The patient´s condition improved progressively and she was discharged at day 8 (NIHSS=5, mRs=2). Close surveillance and monitoring with vascular reassessment is essential to define the correct therapeutic strategy in patients with progressive symptoms. Selected patients with neurologic deterioration, clinical-imaging mismatch and persistent basilar occlusion may benefit from delayed endovascular revascularization and still achieve good outcomes.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P2

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Poster


Multiple iatrogenic lesions after preoperative embolization of hypervascular nasal tumor - read full article

By: Ricardo Martins, Ângelo Carneiro, Viriato Alves, Rui Felgueiras, João Teixeira, and João Xavier

Introduction: Pre-surgical embolization of head and neck tumors is an established procedure, aimed to decrease the blood loss during surgery and to facilitate complete resection. However, severe complications might occur during these embolizations. 
Case Presentation: A 34-year-old woman with a vascularized benign tumor in the right nasal cavity was referred for pre-surgical embolization. Tumor was devascularized with embolic microspheres, injected at the origin of the sphenopalatine artery. After the embolization, the patient complained of loss of vision on the right (became amaurotic) and selective injections depicted a previously unseen anastomosis between the branches of the sphenopalatine and the ophthalmic artery (via ethmoidal branches). Alteplase was injected into the ophthalmic artery ostium, to try to restore flow in the central retinal artery (without success). After the procedure, left hemiparesis was observed and MRI showed cerebral infarcts in the right carotid territory secondary to iatrogenic dissection of the right internal carotid artery. Iatrogenic livedo reticularis also occurred in the glabellar and right malar region.
Discussion: The reported incidence of a severe complication associated with pre-surgical embolization of head and neck tumors is less than 2%. One of the most feared complications is central retinal artery occlusion. Arterial dissections might occur during endovascular procedures but are seldom symptomatic. During endovascular treatment of stroke, an incidence of carotid dissections between 0.25-3.5 was reported. In therapeutic procedures, the risk may be higher due to the more frequent exchange of catheters and the greater number of passages of these devices. 
Conclusion: Multiple severe iatrogenies occurred, despite the adequate technical execution. Pre-surgical embolization is not free of risks, and requires multidisciplinary discussion and rigorous technical planning.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P3

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Poster


Is there a smoking paradox in acute ischemic stroke angiographic recanalization? - read full article

By: Rita Gameiro, Yasmin Mamade, Carolina Pinheiro, Catarina Perry da Câmara, Sofia Galego, Patrícia Ferreira, and Ana Paiva Nunes

Background: The smoking paradox is a controversial phenomenon that refers to an unexpectable better outcome in smokers eligible for thrombolytic treatment. Recent studies suggest that current smokers have better recanalization rates after thrombolysis with the recombinant tissue plasminogen activator (rt-PA). However, there is no literature regarding the effect of smoking on revascularization rates after mechanical thrombectomy. Objectives: We investigated the association of smoking with successful revascularization in patients with large vessel occlusion treated with mechanical thrombectomy. 
Methods: We included 208 of 213 patients with acute ischemic stroke submitted to mechanical thrombectomy during a one-year period. Recanalization rate was defined as a score superior to 2b in the thrombolysis in cerebral infarction (TICI) scale, after endovascular therapy. Smokers were defined according to active or previous smoking habits.   
Results: Among 208 patients, 14 were smokers (n=29). Smokers were younger (median, 59 years versus 73 years; P=0.08), more often men (83 versus 42; P<0.001) and had a higher prevalence of coronary disease (59 versus 11; P<0.01). Smoking status was not associated with different arterial occlusion sites (P=0.141). Smoking did not improve recanalization rates after mechanical thrombectomy (93 versus 87; P=0.55). 
Conclusions: Smoking does not appear to cause better recanalization rates in patients submitted to endovascular therapy. Because of the small numbers, these results need to be validated at a bigger scale.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P4

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Poster


Diffusion tensor imaging in acute hemiparetic stroke patients submitted to thrombectomy—a pilot study - read full article

By: Carolina Figueira, Isabel Fragata, José Manuel Amorim, Jaime Pamplona, and João Reis

Background: Stroke is a leading cause of long-term disability in adults. Diffusion tensor imaging (DTI) parameters, fractional anisotropy (FA) and apparent diffusion coefficient (ADC) measure the integrity of white matter and cytotoxic edema, respectively. DTI quantification in subacute and chronic ischemic stroke has been shown to be related to corticospinal tract damage and to the motor outcome. Purpose: We aimed to evaluate DTI parameters in the acute phase of ischemic stroke, and compare these parameters with matched controls. Materials and Methods: We retrospectively evaluated 13 patients with anterior circulation stroke submitted to mechanical thrombectomy between January 2014 and December 2015. DTI evaluation was performed in the first 10 days after ictus. We measured the mean FA and ADC using regions of interest (ROIs) in the middle cerebral artery territory. The same analysis was repeated in matched control patients. Non-parametric tests were used to compare groups. 
Results: We analyzed a total of 13 stroke patients and 13 control patients. In the stroke group, the median age was 55 years (range 43-80) and 61.5 were female. Mean FA value in the posterior limb of the internal capsule (PLIC) was significantly lower in the affected side when compared to the normal side in the stroke group (0.68±0.11 vs 0.72 ±0.08; p=0.05). Mean ADC was significantly lower in the lenticular nucleus in the affected side in the patients group (667.0 ±171.0 mm2/s vs 745.2 ±70.6 mm2/s; p=0.013). There were no differences in the mean FA and ADC values between the affected side of patients and the same hemisphere in controls, and between the unaffected side in patients and the controls. 
Conclusions: In this exploratory study using DTI we found significantly lower mean FA in the PLIC and lower mean ADC in the lenticular nucleus on the affected side in stroke patients, when compared to the contralateral hemisphere. Further research is warranted to confirm these results and to evaluate a possible role of DTI as a prognostic tool in acute ischemic stroke.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P5

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Poster


Endovascular treatment of acute posterior circulation ischemic stroke—outcomes of a single centre 14 months experience - read full article

By: Manuel A. Correia, Francisco Raposo, Mário Mendonça, Carla Guerreiro, Pedro Teotónio, Gonçalo Basílio, Paulo Sequeira, Luísa Biscoito, Lia Lucas Neto, and Jorge Campos

Background and Objectives: Posterior circulation strokes account for 15-20% of all ischemic strokes and are associated with high disability. Variable and ill-defined symptoms may delay the diagnosis and increase morbimortality. Early recanalization seems to be associated with better clinical outcomes; however, the best management is still uncertain. Experience with stent retrievers is limited and this technique is usually combined with other therapies. In this study, we analyzed the imaging and clinical outcome after treatment with mechanical thrombectomy. 
Methods: Since our center became part of the metropolitan emergency service for stroke (January 2016), more than 130 patients were admitted in the department of interventional neuroradiology. Of these, 10 had acute posterior circulation ischemic stroke and underwent endovascular mechanical thrombectomy. Clinical and angiographic data were collected. Success of the thrombectomy was defined as Thrombolysis in Cerebral Infarction (TICI) > 2, and good clinical outcome as a value in the modified Rankin Scale (mRS) < 3. 
Results: The median age of the patients was 70.7 ± 8.86; mean National Institutes of Health Stroke Scale (NIHSS) on admission was 23.1 ± 5.7. Recanalization was successful (TICI > 2) in 7 of 10 patients (70). At 3 months, 40% of the patients had mRS < 3 (good and moderate clinical outcome), 40% had mRS 4-5 (poor clinical outcome), and 20% had mRS = 6 (dead). 
Conclusion: Mechanical thrombectomy of acute ischemic stroke of the posterior cerebral circulation was found to be associated with high successful recanalization. We also observed favorable clinical outcome in an important percentage of patients.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P6

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Poster


Relationship between density of thrombus on admission CT and mechanical thrombectomy inefficacy - read full article

By: Mário Mendonça, Francisco Raposo, Manuel A. Correia, Carla Guerreiro, Pedro Teotónio, Gonçalo Basílio, Paulo Sequeira, Luísa Biscoito, Lia Lucas Neto, and Jorge Campos

Background and Objectives: Ischemic stroke is one of the major causes of death and disability. Vessel opening is one of the goals of treatment and earlier recanalization correlates with better outcomes. During some interventions, we noticed that many of our pulls were unsuccessful, even though the same technique and devices were used. Is there any thrombus characteristic on the admission CT scan, including its density in Hounsfield Unit (HU), that can predict the failure of a recanalization (patients with Thrombolysis in Cerebral Infarction (TICI) < 1) following Mechanical Thrombectomy? 
Methods: We selected the patients that underwent Mechanical Thrombectomy in our centre for anterior circulation acute stroke (with or without previous tPA) with a final TICI < 1; and the patients with a final TICI = 3 (complete recanalization). Then, we retrospectively reviewed the admission non-contrast CT scans of these two groups, comparing the clot characteristics, including the absolute clot density in HU. 
Results: We identified 117 patients with anterior circulation stroke treated with mechanical thrombectomy. In the TICI < 1 group (11.11 of the patients), we observed lower density value of the clot (mean absolute HU 46.5 ± 7.33) vs. the TICI = 3 group (13.67) with higher density value of the clot (mean absolute HU 56.06 ± 3.57). Within the observed groups, we did not identify any other consistent thrombus characteristic. 
Conclusion: In this retrospective study, we observed that failure of recanalization during mechanical thrombectomy correlates with lower HU values of the thrombus. This aspect may be related to the composition of the thrombus, formed mostly of fibrin and platelets, as opposed to those constituted mainly by red blood cells. Such information could be used in decision making when estimating recanalization success rate with endovascular treatment approaches.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P7

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Poster


Aspiration Thrombectomy of M2 occlusions: a single center analysis - read full article

By: Carolina Pinheiro, Isabel Fragata, Mariana Diogo, Sofia Galego, Catarina Perry da Câmara, Patrícia Ferreira, Jaime Pamplona, Marcos Veiga, Ana Paiva Nunes, and João Reis

Background: Recent studies have shown that mechanical thrombectomy is safe and improves functional outcome in patients with acute ischemic stroke (AIS) due to intracranial carotid artery or proximal (M1) middle cerebral artery (MCA) occlusions. It is unclear if patients with distal MCA occlusions such as M2/M3 also benefit from endovascular treatment (EVT) without additional risks. 
Objectives: To review the occurrence of thrombectomy after IV tPA in acute ischemic stroke due to a M2/M3 occlusion, in our single center, and to assess the clinical outcomes and associated complications. 
Methods: We conducted a retrospective review of patients who underwent thrombectomy after IV tPA for treatment of an acute M2 or M3 occlusion between January and December 2016. Patient’s medical records (demographic data, endovascular treatment complications, NIH score at 24h), angiographic results and clinical outcome using the modified Rankin score (mRS) at 90 days were reviewed. 
Results: Of a total of 24 patients, 23 patients had M2 occlusions and 1 patient had an M3 occlusion. Aspiration thrombectomy was performed in 24 patients. Three patients were treated with both stent retriever and aspiration thrombectomy. There was a female prevalence (15 vs 9 male patients). The mean age was 76.2 years old. The main risk factor was hypertension in 21 patients. The rate of successful recanalization (TICI grade ?2b) was 75% (18 of 24 patients). There were no significant complications related to the thrombectomy procedure. The median NIHSS at admission was 13 (range: 4 - 23) and the median NIHSS at 24 hours was 10 (range: 1 - 26). At three months, 9 patients (37.5%) had favorable clinical outcome (mRs<2). Two patients (8%) had symptomatic hemorrhagic transformation (HI2). Mortality at 3 months was 16.6% (4 patients). 
Conclusion: EVT of M2 and M3 occlusions, in selected patients, can result in a good outcome, with a low rate of complications. Further prospective studies are necessary to confirm these observations.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P8

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Poster


Decompressive craniectomies for malignant anterior circulation infarction—evaluation of in-hospital prognosis - read full article

By: Pedro Moura Branco, Gonçalo Januário, Lino Fonseca, Dalila Forte, Ricardo Nogueira, Luís Cardoso, Ana Paiva Nunes, and Carlos Vara Luiz

Objective: Analyse the in-hospital prognosis of patients submitted to decompressive craniectomy (DC) for anterior circulation malignant stroke. 
Methods: Retrospective analysis of consecutive patients submitted to DC for anterior circulation malignant stroke, for a period of 5 years in a tertiary centre. Demographic, imagological and surgical data, as well as neurological outcome, were analysed; factors associated with in-hospital mortality were determined. 
Results: Among 41 patients, the average age was 57.46±12.1 years, 56.1% were male and 53.6% had right-sided infarction. 32 of the surviving patients achieved a Rankin score >3. Mortality was 46.3%, and associated with higher ages (62.7±10.8 vs 53.4±11.8;p=0.013). Preoperative midline shift (MDS) of >10 mm was predictor of mortality (OR 4.2;p=0.038). Presence of anisocoria was associated with 66.7% mortality versus 33.3% (p=0.058) without its presence. No postoperative MDS was associated with 33.3% mortality versus 54.5% on those that maintained MDS (p=0.093). Patients under 65 years old with isolated middle cerebral artery infarction (MCA) (n=22) presented a mortality of 31.8% versus 57.8% on those that did not fulfilled one of these criteria. Mortality in patients over 65 years old reached 77.8%, with all survivors presenting an isolated MCA infarction. On the subgroup of patients with more than one ischemic territory and under 65 years, the mortality was 40% (versus 100% over 65 years), with only one patient reaching Rankin score <3.
Conclusion: Age and preoperative midline shift were associated to in-hospital mortality. Patients >65 years and/or >1 ischemic territory presented the worst prognosis. 

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P9

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When things get complicated but are reversible… - read full article

By: Valentina Tosatto, Cristiano Cruz, Torcato Marques, Paula Nascimento, Zsófia Vesza, André Almeida, and Rita Barata Moura

Clinical Report: The patient was a 33-year-old Nepali woman, living in Portugal, previously healthy, thirty-three weeks pregnant, with second trimester gestational diabetes. She was admitted at the gynecology emergency room with preeclampsia and HELLP syndrome, and underwent urgent cesarean delivery for fetal bradycardia. She was then transferred to the intensive care unit due to clinical worsening, resistant hypertension, acute kidney injury and non-cardiogenic pulmonary edema. When a decrease of sedoanalgesia was attempted, significant psychomotor agitation ensued. Head CT scan showed signs of Posterior Reversible Encephalopathy Syndrome (PRES), namely in the bilateral parietal and occipital cortico-subcortical areas. A second CT scan showed hypodensity of the left fronto-temporo-parietal cortico-subcortical area, clinically associated with right hemiplegia. Two weeks later, hemorrhagic conversion of the left cerebral hemisphere injury ensued, without mass effect or increased extension. Electroencephalography was normal and transcranial doppler showed mild vasospasm in major arteries. Two months later, there was clinically significant improvement, with the patient showing normotensive profile and total renal function recovery, even though maintaining aphasia and moderate right hemiparesis, partially improved. MRI showed favorable evolution of PRES signs. 
Conclusions: This case represents an example of PRES associated with HELLP syndrome, with unusual involvement of anterior cerebral areas. The anterior left injury was probably multifactorial, including autoregulatory failure in a non-chronic hypertensive patient, endothelial dysfunction associated with preeclampsia and local hypoperfusion with cerebral infarction due to reactive focal vasoconstriction (described in more severe cases). Hemorrhagic conversion is also an unusual event.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P10

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Ischemic stroke in cancer patients - read full article

By: Catarina Valente Bexiga, Vilma Laís Grilo, Ana Raquel Miranda, Melanie Duarte Serra Ferreira, Ana Glória Fonseca, and Maria Francisca Delerue

Background: The association between venous thromboembolism and malignancy is well known. How arterial events and cancer are related is less clear. Objectives: To evaluate cardiovascular risk factor (CVRF) profile in cancer patients admitted for ischemic stroke (IS), as well as stroke ethology. 
Methods: A hospital-based retrospective study consisting in the analysis of admissions between January 2013 and December 2016 was conducted. Clinical files whose final diagnoses included ICD-9 codes pertaining IS and any solid neoplasia were reviewed. Variables included underlying malignancy, CVRF profile and IS etiology. For statistical analysis, we used IBM SPSS version 23. The significance level was 0.05. 
Results: We identified 109 patients, with 58.7% men and an average of 75.5 years. Gastrointestinal tract cancer was the most common (22.9%) neoplasia, and most tumors were adenocarcinomas (59.6%). At admission, 55 of the patients had active malignancy. The most frequent CVRF was hypertension (80%). One-third of the patients had atrial fibrillation, which was associated with non-adenocarcinoma histology (X2, p=0.001). Most patients had already known malignancy. In 8 of them, cancer was diagnosed during hospital admission. TOAST etiology was “undetermined” in half of IS and undetermined etiology was associated with adenocarcinoma histology (X2, p<0.001). 
Conclusion: In this study, age, hypertension and atrial fibrillation were the most relevant CVRF for IS as a first arterial thromboembolic event in patients with solid neoplasia. An important percentage of IS had “undetermined” etiology, especially in patients with adenocarcinoma, thus indicating that there is still much to unveil in the association between IS and cancer.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P11

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Hemorrhagic stroke in children: expect the unexpectable - read full article

By: Catarina Perry da Câmara, Marcos Veiga, Carolina Pinheiro, Teresa Morais, João Jacinto, Isabel Fragata, Carla Conceição, and João Reis

Background: Pediatric stroke is unexpectedly common, with an incidence in children between 28 days old and 18 years old of 2.3 to 13 per 100,000/year. Contrary to the adult population, in children, 45% of strokes are hemorrhagic and the most common cause is vascular anomalies. Albeit the incidence, median time to diagnosis is about 23 hours, impairing the prognosis. Objectives: This work aims to alert the medical community about hemorrhagic stroke in children. 
Methods: A review of our Neuroradiology database was performed for hemorrhagic stroke in children. Best imaging examples were selected. 
Results: We present a pictorial review of different presentations and etiologies of hemorrhagic stroke on CT, MRI and angiography. A systematic imaging approach to diagnosis was performed. Cases to be shown include: arteriovenous malformations, aneurysms, cavernous malformations, sickle cell disease and coagulopathies such as: leukemia, anticoagulation treatment or hemophilia. In addition to this review, we also put in perspective the delay in diagnosis, opening discussion to what needs to be done to prevent it. 
Conclusion: Hemorrhagic stroke is an important cause of morbidity in children. Doctors’ awareness and rapid neuroimaging are essential to a prompt diagnosis.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P12

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Ischaemic stroke related to chronic cannabis use—a case report - read full article

By: Sónia Almeida, Marta Cerol, Ana Alves Oliveira, Marta Valentim, Ana Gameiro, and Margarida Cabrita

Introduction: Several case reports support a causal link between cannabis use and cerebrovascular events, as cannabis may lead to reversible cerebral vasoconstriction syndrome and multifocal intracranial arterial stenosis (MIS). 
Case description: A 37-year-old male patient with no known classical vascular risk factors woke up with dizziness and numbness in the right side of the body. He avowed to be a chronic cannabis consumer. At admission, his vital signs were normal. On neurological examination, he exhibited hemiparesis (1/5 motor power) in his right upper extremity and loss of the right nasolabial sulcus, presenting a NIHSS (National Institutes of Health Stroke Scale) of 2. Cranial tomography (CT) revealed an acute ischaemic infarct over the left parietal lobe and vascular sequelae in the territory of the deep penetrating branches of the left middle cerebral artery (MCA). CT angiography of the extracranial neck vasculature and all laboratory examinations were normal. Due to the presence of multiple strokes, an embolic source was searched (24h Holter, transthoracic and transoesophageal echocardiograms). Magnetic resonance imaging detected a chronic infarct in the left temporal lobe and multiple lacunar strokes (some with increase in restriction diffusion-weighted imaging) in the left MCA territory, suggesting the existence of an underlying vasculopathy. 
Discussion: Chronic cannabis use is associated with increased cerebrovascular resistance and has been temporally associated with paroxysmal atrial fibrillation. Although this possibility could not be ruled out completely in this patient, the absence of cardiac symptoms, the normality of the echocardiographic studies, and the absence of systemic embolic events made this possibility unlikely, favouring the likelihood of a MIS.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P13

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Causes for clinical deterioration four and five days post thrombolysis - read full article

By: Rafael Nascimento, João Miguel Freitas, Patrício Freitas, José Franco, Duarte Noronha, Rafael Freitas, and Luz Brazão

A 64-year-old man was brought to the emergency department (ED) with sudden right-sided weakness and slurred speech. The patient referred a sudden onset of loss of power on his upper right limb during lunch. He went to a nearby Health Centre and was immediately sent to the local Hospital. At the Hospital, the man was examined one hour after the onset of his weakness. He was apyrexial and hemodynamically stable with a blood pressure of 164/92 mmHg. He had partial hemianopsia, dysarthria and right brachial hemiparesis. The patient had a NIHSS of 9 and the brain CT scan showed no acute lesions. He initiated thrombolysis 2 hours and 14 minutes after the onset of the symptoms with progressive clinical improvement; 4 hours later, his NIHSS was 5. The 24-hour control brain CT showed a hypodensity in the left hemisphere (temporal parietal location) consistent with an acute infarction. During his stay in the stroke care unit, the patient had a clinical deterioration (NIHSS 9) when he woke up on the 4th day. The following day, the patient suffered a transitional episode of dizziness and diaphoresis when trying to stand up slowly, with further aggravation of the NIHSS scale to 11. The neck duplex scan showed a stenosis of 70-80% in the left common carotid bifurcation and beginning of the internal carotid artery. That same day, the patient developed a pneumonic infection with a chest x-ray showing a heterogeneous infiltrate. The brain CT showed an enlargement of the initial lesion, with a small haemorrhagic transformation, 8 days after admission in the ED. The authors pretend to discuss the reason or reasons for clinical deterioration and debate the best treatment in this patient with a past story of radiotherapy in 2014, due to a throat cancer.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P14

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Direct puncture of the carotid artery for thrombectomy in acute stroke patients—back to the old Egas Moniz technique - read full article

By: Mariana Baptista, Luis Fontão, Isabel Fragata, Ana Paiva Nunes, and João Reis

Background: In the late twenties, Egas Moniz introduced cerebral angiography by injecting a radio-opaque medium directly in the cervical carotid artery. The femoral Seldinger technique replaced direct carotid access, and is the current state of art. However, in particularly difficult anatomical configurations, percutaneous access through the carotid artery may be justified. 
Material and Methods: Retrospective review of clinical and imaging data of stroke patients, submitted to Digital Subtraction Angiography (DSA) at Hospital São José by direct carotid artery puncture, between January 2014 and December 2016. 
Results: A total of 3 patients, referred to our hospital under the acute stroke protocol, were submitted to DSA by direct carotid artery puncture for large vessel occlusion stroke. Significant tortuosity and difficult anatomy did not allow selective catheterization through femoral access. Mechanical thrombectomy with aspiration system was performed in two of them, with successful recanalization, TICI 3. In the third patient, by the time the vessel was reached, spontaneous recanalization had occurred. Two of these patients were also submitted to intravenous thrombolysis, so a closure device was used; in the third, a manual compression was done to achieve hemostasis. There were no periprocedural complications. Post-procedural complications included percutaneous hematoma in one patient, which resolved spontaneously, with no need for intubation. 
Conclusions: At a time when endovascular treatment is part of the guidelines for the treatment of large vessels occlusion strokes, high-risk patients with no femoral access or difficult anatomy may benefit from direct carotid artery puncture, despite the risks involved.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P15

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How bad is a TICI 2? - read full article

By: Luís Fontão, Mariana Baptista, Jaime Pamplona, Isabel Fragata, Clara Ribeiro, and João Reis

Background: Successful reperfusion is a predictor of good outcome in acute ischemic stroke (AIS), following mechanical thrombectomy (MT) for large-vessel occlusions. Technical success in endovascular therapy has been defined as TICI score 3 or 2b in several studies, although scarce data is available on clinical outcome in patients in whom a lower TICI (0-2a) was achieved. 
Objective: To examine the functional outcome of patients subjected to MT for anterior circulation large-vessel occlusion, with TICI 0-2a recanalization score. 
Methods: Single-center retrospective analysis of the subset of TICI 0-2a, from consecutive 177 patients treated with MT for acute anterior circulation large intracranial artery occlusion, from January 2016 to December 2016.  
Results: Of 177 patients, 21 were included, with 12 women (57%) and a mean age of 64.2 years (SD 18.4). Mortality rate was 23%. Two groups were defined based on clinical outcome, defined as 3-month modified Rankin Scale (mRS) 0-2 (n=4 – 19) or >2 (n=17 - 81). The group with good clinical outcome (n=4) had younger ages (mean 47 years, SD 17.4 versus 68.2 years, SD 16.6), lower median intervention time (53 minutes versus 98.5 minutes) and no intracranial hemorrhage (versus 11.8 on the worst clinical outcome group). No difference was found on stroke etiology, site of occlusion, previous mRS or onset-reperfusion among the two groups.  
Conclusion: Most patients with incomplete or absent reperfusion had an unfavorable clinical outcome, whilst heterogeneity was found among younger patients. Further studies with larger samples are warranted to determine prognostic factors among these patients.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P16

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Looking for the culprit in stroke: what to do when the plot thickens? - read full article

By: Ricardo Soares-dos-Reis, Ana Monteiro, Marta Carvalho, Pedro Abreu, Paulo Chaves, and Elsa Azevedo, Tiago Parreira, Carina Reis, Luísa Fonseca, and Pedro Castro

Background: Stroke etiological investigation is usually a standardized process, where clinical and test findings are taken together. In a significant proportion of cases, no definite etiology is found, either because of negative findings or multiple causes. Here, diagnostic and therapeutic decisions were not straight-forward. 
Case report: 70-year-old man complained of acute left hemiparesis. He had left homonymous hemianopia, sensory extinction and mild hemiparesis. CT showed a right temporo-parietal infarction. Echocardiogram, cervical and transcranial Doppler and 24h Holter monitoring had no significant findings. After 4 months, he was enrolled in an embolic stroke of undetermined source clinical trial. After 1 month, he had self-limited episodes of left hand tingling and later was admitted for left leg paresis. His aPTT was prolonged. CT showed a new right caudate-capsular infarction. MRI showed recent right subcortical temporo-parietal ischemia; MRA revealed irregular caliber and stenosis of the internal carotid artery (ICA), compatible with dissection or other vasculopathy, which improved in follow-up MRA, 7 days later. CSF analysis, including VZV, was normal. Trial oral anticoagulant (OAC) was stopped. After 1 month, he noticed a throbbing headache and red right eye. Angiography and ultrasonography revealed right thrombotic proximal ICA occlusion. OAC was started. After 1 month, readmission due to multiple episodes of left-side weakness. Doppler monitoring showed microembolization with right ICA origin. Hypocoagulation was stopped. Aspirin was started with no recurrent events within a 2-month follow-up. 
Conclusion: Although a clear-cut etiology was elusive, the consensus was ICA dissection. Discussing safety/efficacy of novel OAC in ICA dissection is warranted.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P17

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Should you treat your elderly, demented and dependent grandmother? - read full article

By: Soraia Vaz, Patrícia Ferreira, Sofia Galego, Isabel Fragata, João Reis, and Ana Paiva Nunes

Background: Elderly patients – ?80 years old – with acute ischaemic stroke (AIS) are frequently excluded from reperfusion therapy. Pre-existing dementia and disability – modified-Rankin-scale (mRS) X2, while not absolute contraindications, are outcome predictors often considered in the decision-making process. 
Case report: A 85-year-old demented woman with a mRS score of 3, presented with acute onset global aphasia, head and conjugate eye deviation to the left, right homonymous hemianopia and right hemiparesis, scoring 23 points in the National Institutes of Health Stroke Scale (NIHSS). The emergent brain computed tomography (CT) failed to reveal early ischaemic signs, and the CT angiography uncovered a left internal carotid artery T-occlusion. Intravenous fibrinolysis (alteplase, 0.9mg/kg) was started at 139 minutes from symptom onset. An angiography was then performed, confirming a left T-occlusion, and a mechanical thrombectomy (MT) was performed, achieving total recanalization. Follow-up brain magnetic resonance imaging 24 hours after treatment revealed a recent ischaemic infarction of the left lenticulo-capsulo-caudate and corona radiata areas. Sustained clinical improvement was attained and, at the 3-month follow-up consultation, she had recovered from her motor deficits being able to walk, but kept meaningful language compromise and scored a mRS 3. 
Conclusion: We report a case of AIS in an elderly demented woman with a baseline mRS score 3, successfully treated with fibrinolysis and MT. Such examples support current beliefs that neither age, nor cognitive impairment or pre-existing disability alone or coexisting should be considered exclusion criteria for reperfusion therapy.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P18

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Multiple intracranial stenoses: can we find the guilty one? - read full article

By: Luís Fontão, Luis Ruano, and José Roriz

Patient was a 65-year-old men without relevant medical history or known vascular risk factors. He presented to the ER 2 days after a transitory episode of dysarthria and right-sided hemiparesis that lasted for less than 30 minutes. Neurological examination was normal. Brain CT showed only diffuse leucoariosis and a right lenticulo-radiate lacunar sequel. Multiple arterial stenoses were found on cervical/transcranial doppler ultrasound (C/TCD), including criteria for a 50% stenosis of the right cervical ICA, 70% stenosis of the right terminal ICA, 50% stenosis of the left terminal ICA, 70% stenosis of the basilar artery and 50% stenosis of the left PCA. Extensive workup was taken, including 24h-Holter, transthoracic echocardiography, ABPM, glycemic/lipid profile, thrombophilia, immunological and CSF screen; everything was normal. The patient was started on Atorvastatin 40mg and Clopidogrel. He was again admitted in the ER, about 4 months later, with an acute isolated left VI nerve paresis, and was discharged on dual antiplatelet treatment (AAS 150mg and Clopidogrel 75mg), with spontaneous improvement over the following weeks. The patient returned to the ER about a year later with an acute left-sided ataxic-hemiparesis syndrome persisting for the previous 24 hours. A brain MRI was performed, disclosing extensive microangiopathic brainstem and subcortical sequels, plus an acute paramedian right pontine lacunar infarct. C/TCD reevaluation suggested a progression of the stenoses previously documented in the left PCA and basilar artery, while remaining stable in the carotid axes. He remained treated with Atorvastatin 80mg, AAS and Clopidogrel, and was started on Enalapril + Amlodipine. Marked improvement was seen in the subsequent weeks, with no further events reported in a 6-month follow-up. Conclusion: Can the patient be further studied regarding etiology? Could all 3 symptomatic episodes be related to the basilar artery stenosis? Should the patient be (or have been) submitted to intracranial stenting of the basilar artery? Could the treatment plan be optimized with any other antiplatelet/statin combination?

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P19

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Stroke as an unusual manifestation of systemic diseases: three case reports - read full article

By: João Pedro Figueira, Maria Inês Ferreira, Raquel Silva, Tiago Serra, Isabel Cravo, and Fernanda Paixão Duarte

In stroke there is a sudden damage of brain cells in a localized area due to inadequate blood flow. Several pathophysiologic processes may be involved: intrinsic to the vessel or to the blood; embolic; hypoperfusion; and rupture of a vessel. Various systemic conditions may trigger these processes and cause brain ischemia. The authors present three cases of ischemic stroke: Case 1: A 26-year-old woman with systemic lupus erythematosus was admitted with headache and seizures. Cranial CT revealed left ischemic lesions. The patient then presented newly onset right hemiparesis. Cranial MRI confirmed subcortical lesions. Cyclophosphamide and corticosteroids were administered with improvement of general status and the patient was discharged with minor sequelae. Case 2: A 28-year-old pregnant woman with 34 weeks of gestation, previously healthy, was admitted with severe headache and nausea. Cranial MRI showed thrombosis of left lateral dural sinus. The patient had obstetric history of one low-weight term birth. The investigation of prothrombotic states was suggestive of antiphospholipid syndrome and treatment with metilprednisolone, aspirin and low molecular weight heparin was started. The birth occurred at 38 weeks of gestation without complications and the newborn was healthy and normal weighted. Case 3: A 36-year-old woman, with history of tuberculosis, in the third month of antibacilar therapy, was admitted with left peripheral facial paralysis and lack of strength on the right side of the body. During hospitalization, the patient presented left hemiplegia and worsening of the state of consciousness. Cranial CT scan showed right ischemic stroke and hydrocephalus. Ventriculoperitoneal shunt was performed with consciousness improvement but persistence of left hemiplegia.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P20

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Floating carotid plaque thrombus: a case of watchful waiting approach - read full article

By: Carolina Pinheiro, Patrícia Ferreira, Mariana Diogo, Isabel Fragata, Sofia Galego, Catarina Perry da Camara, Ana Paiva Nunes, and João Reis

The patient was a 51-year-old female university professor, with history of smoking, C7-D1 disc hernia surgery in 2014 and two episodes of right hemiparesis in November 2016 – interpreted as transient ischemic attacks – and under oral antiplatelet since. In February 2017, the patient had acute onset of dysarthria and left hemiparesis. In this context, the Stroke Code (Via Verde AVC) was activated. At hospital admission, the patient was conscious, without dysarthria or language deficits, facial asymmetry, visual field defects or ophthalmoparesis. She had a mild right hand paresis, but no associated sensitive deficits. Her NIHSS score was 2. Even before the brain computed tomography (CT) was performed, right hand strength was recovered. Head CT showed no acute parenchymal lesions. AngioCT of the supra-aortic vessel depicted a severe post-bulbar stenosis of the left internal carotid artery (ICA) over a short segment and was suggestive of an associated luminal thrombus. Despite the severe carotid stenosis, no intravenous fibrinolysis was administered, given the low NIHSS score. It was also decided not to perform any endovascular procedures at that time and the patient was admitted to a stroke unit for further vascular workup and vigilance. Carotid ultrasound study confirmed the endoluminal thrombus with oscillatory movements in the origin of the left ICA and the hemodynamic study was compatible with a severe stenosis of the proximal segment of the artery. Given these findings, it was decided to maintain the patient on an oral antiplatelet and start anticoagulation with enoxaparin, with posterior bridging to warfarin. Brain magnetic resonance imaging showed small acute ischemic lesions on the left: in the posterior frontal white matter, corona radiata and transition between the caudate head and body. Serial carotid ultrasound studies showed complete resolution of the thrombus, with a persistent atherosclerotic stenosis of 50-60%. The patient had a favorable clinical evolution, with a NIHSS score of 0 at hospital discharge. Diagnosis at discharge was atherosclerotic acute ischemic stroke. Conclusion: The doubt persists - was watchful best medical treatment indeed the best option, or would acute phase thrombectomy have been a better one?

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P21

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Off-label thrombolysis in simultaneous stroke and pulmonary embolism - read full article

By: Mourão Carvalho, Ana João Carvalho, Rita Moça, Helena Moreira, Inês Albuquerque, Nuno Príncipe, Pedro Castro, Paulo Chaves, Luísa Fonseca, and Jorge Almeida

Stroke and pulmonary embolism (PE) are emergent situations with specific performance guidelines. Their simultaneous occurrence is rare. We describe a case of a 20-year-old women, otherwise unremarkable past and familial medical history except for overweight and oral contraceptive use. She was admitted at the emergency room 45 min after suffering a witnessed seizure. She recovered consciousness but remained with motor aphasia, central facial and right arm paresis, scoring 7 in NIHSS. She was hemodynamically unstable, with low blood pressure and sinus tachycardia and polypnea. She was in hypoxia and respiratory alkalosis and her electrocardiogram in sinus tachycardia showed profound T-wave inversion at DII, DIII, aVF and V1-V5 plus S1Q3T3 pattern. Brain-CT and blood analysis were normal. Pulmonary angio-CT revealed extensive bilateral PE. Intravenous infusion of 100 mg of alteplase over two hours was administered. The patient progressively improved both hemodynamic, respiratory and neurologically, scoring 2 in NIHSS at the end of the treatment. A transthoracic echocardiogram revealed a patent foramen ovale with an atrial septal aneurysm and a right-to-left shunt. A lower limb Doppler revealed a recent left gastrocnemial and popliteal thrombosis. Unfractionated heparin perfusion was started. A brain-magnetic resonance showed left temporoparietal infarction. The two thrombolytic therapy protocols are quite different. In this specific case, the right protocol is not defined in the literature due to its rarity. Despite its hemorrhagic transformation risk, we opted to treat the most life-threatening condition. Discussing the best therapeutic strategy is an off-label but potentially lifesaving approach.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P22

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