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Issue 5 (2018) – Supplement 1


Special Issue from the Lisbon Stroke Summit

This supplemental issue comprises the abstracts from the Lisbon Stroke Summit 2018, Lisbon, Portugal. 6–7 April 2018.

Guest editors:
Ana Paiva Nunes
Elsa Azevedo

Issue Nr:

5

|    Issue date: 2018-04-06

Guest Editorial


Lisbon Stroke Summit 2018—deep into the stroke patient management decisions - read full article

By: Ana Paiva Nunes and Elsa Azevedo

After the success of its first edition, Lisbon Stroke Summit 2018 focus again in the stroke patient management decisions. Along with the pros and cons debate of unsolved issues, difficult clinical cases are discussed by the stroke experts of this international forum. In a world of clinical trials where we try to prove the benefits of an intervention in a big sample, sometimes we forget that patients are all different, and we need to come back to the old meetings discussing them individually. Our patient might have features not compatible with the strict inclusion and exclusion criteria of the trials, and therefore our concern is the patients who do not fit the guidelines. This meeting aims to join vascular clinicians, internists and neurologists, as well as neurointerventionalists, from different countries and with different perspectives, but having in common the experience of treating patients with stroke. All the knowledge gathered in this meeting will certainly help all the participants to better understand and manage the most challenging clinical cases of their practice. We believe that this perspective of returning to the basics in medicine, to the individual patient, is needed and should be stimulated because it is the core of clinical practice.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):S1

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Lecture


Translational Stroke Research: a personal perspective - read full article

By: Marc Fisher

Translational stroke research traditionally encompasses the passage of basic science advances into clinical medicine. It is a key component in the process of developing novel therapeutics and diagnostic capabilities. Traditionally translational research has occurred as research teams focus on important basic science discoveries that may have clinical utility and evaluate these advances in animal models. However, other translational research pathways have evolved and can be characterized as reverse translation where clinical advance stimulate basic science researchers to study mechanisms of disease pathophysiology or drug activity. Lateral translation occurs when basic researchers attempt to enhance or modify the activity of a drug to improve its safety and/or efficacy profile. An example would be the development of improved thrombolytic drugs that has better clot-lysis activity than tPA and is safer. Translational stroke research requires a large team with many individuals from multiple diverse backgrounds who can work together in a productive environment.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):L1

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Lecture


Biomarkers in acute stroke - read full article

By: Joan Montaner

Blood biomarkers measurement could add in acute stroke management, in both selecting patients at the pre-hospital level, as well as guiding reperfusion therapies to evaluate efficacy and safety. In acute stroke, blood biomarkers to distinguish between real strokes and stroke-mimics would be useful at pre-hospital level, especially in patients with low symptom severity. In patients with severe symptoms, differentiation between ischemic and hemorrhagic subtypes would permit administration of pre-hospital reperfusion therapies. For this issue, portable CT-scans have been used; however, a wide generalization of these expensive tools seems not feasible in the near future. Thus, having a blood test to differentiate between ischemic and hemorrhagic stroke in the preclinical setting would be desirable. Different plasma biomarkers have been described to differentiate IS from ICH stroke during the acute phase, such as glial fibrillary acidic protein (GFAP). Also retinol-binding protein 4 (RBP-4) is as a promising biomarker to distinguish IS from ICH during the acute phase of stroke. In addition, we demonstrate that when complemented with GFAP, the discrimination of both stroke subtypes is improved. Also, specific biomarkers that selectively evaluate the response to tPA, predict the appearance of secondary intracranial hemorrhages and identify patients with unsuccessful tPA-induced recanalization have gained in importance during the last few decades. On the other hand, the identification of patients resistant to tPA-thrombolysis would be of great interest in deciding whether stroke patients may benefit from alternative therapies such as endovascular thrombectomy. Thus, due to the efficacy of this mechanical method, specific biomarkers to anticipate unsuccessful recanalization after tPA administration are promising. Hence, pre-treatment levels of fibrinolytic inhibitors such as plasminogen activator inhibitor-1 (PAI-1) or thrombin activatable fibrInolysis inhibitor (TAFI), as well as other molecules related with coagulation, such as factor seven activating protease or A Disintegrin And Metalloproteinase with a ThromboSpondin type-1 motif, member-13 (ADAMTS13) have been associated with a poor tPA response in terms of recanalization. Beyond the acute phase, prediction of stroke outcome and the occurrence of post-stroke complications such as stroke-associated infections and assessment of stroke etiology to guide further studies or even therapeutic measures in cases of stroke of undetermined cause represent the main indications for the use of blood biomarkers in the subacute and chronic phases.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):L2

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Debate


Cerebral Venous Thrombosis—go for early EVT: Pros - read full article

By: Diana Aguiar de Sousa

Thrombosis of the cerebral veins and sinuses (CVT) is a distinct cerebrovascular disorder in which the outflow of blood from the brain is blocked, causing increased venular and capillary pressure that leads to parenchymal brain lesions in approximately half of the cases. Despite standard medical treatment with anticoagulation, death or dependence occurs in about 14% of patients. In severe cases requiring transfer to an intensive care unit the mortality rate is up to 30%. In such cases, death is most often due to extensive cerebral edema or hemorrhagic stroke. Although the role of recanalization of the occluded dural sinuses or veins in the outcome of patients with CVT is not well established, evidence from animal models suggests that early venous recanalization has an impact on brain tissue damage and an association between venous recanalization and favorable outcome is seen in patient cohorts. Based on the hypothesis that rapid recanalization of the venous sinuses is key to improve the prognosis in severe CVT, endovascular treatment (EVT) has been successfully used in multiple case reports and small series. More recently, the neutral results of the first randomized comparison of adjunctive EVT versus standard treatment with anticoagulation have increased uncertainty on the effectiveness of this intervention in patients with severe CVT. TO-ACT was a pragmatic trial designed to show the real-world effect of this intervention in a relatively broad patient group. Importantly, decisions regarding the protocol for EVT were left to the treating interventionalists and patients having a single predictor of poor outcome could be included. The neutral results of this trial should pave the way for development of new local protocols and trials on EVT in patients with CVT. Further research on the pathophysiology of brain lesions, prognostic markers and EVT techniques should improve patient selection and standardization of EVT procedures in CVT.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):D1

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Debate


Neurointervention: should we specialize in stroke only? Pros - read full article

By: João Pinho

The treatment of acute ischemic stroke has suffered a change in paradigm, with the demonstration of the benefit of mechanical thrombectomy (MT) in selected patients. The number of MT procedures is rapidly increasing, and stroke networks need to adapt to be able to provide this treatment to the majority of eligible patients. Adaptations are needed in multiple domains, namely in distribution of MT-providing centers, human resources, training of professionals, diagnostic and physical resources, communication systems and transfer protocols. It is being increasingly discussed where should MT be provided, and who should perform it. A solution which ensures high-quality care, in highly differentiated centers, by highly experienced professionals, may not be compatible with an equitable distribution of care, especially in conditions with a high incidence such as ischemic stroke. A balance between quality and expertise of care, and availability and feasibility of care must be achieved, because both the eligibility for and the benefit of MT are time-dependent. Considering the incidence of ischemic stroke in high-income countries (168 per 100.000 persons/year) and the expected proportion of patients eligible for MT (up to 15-20%), the number of MT/year performed in a primary stroke center with a catchment area of 200.000-300.000 inhabitants would be at least similar to the number of MT performed in high-volume centers, as defined presently in the literature. In order to maximize resources, interhospital transfer times and populational density must also be taken into account. Because other conditions, such as vascular malformations, are much less frequent, primary stroke centers will not have enough case volume to perform other endovascular treatments with quality. This does not obviate the need of a comprehensive training in endovascular neurointervention and continuous education and monitoring after accreditation. In conclusion, in the appropriate setting, specialization in stroke by neurointerventionalists is needed.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):D2

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Debate


How low should we go? Can we perform EVT in patients with LVO and low NIHSS? Cons - read full article

By: Lia Lucas Neto

Six randomised controlled trials (RCT) demonstrated superiority of endovascular thrombectomy (EVT) to intravenous tissue plasminogen activator (IV-tPA) alone for acute ischemic stroke caused by an anterior circulation large vessel occlusion (LVO). But most trials excluded patients with low National Institutes of Health Stroke Scale (NIHSS) score. Guidelines give a Class II-b level of evidence for EVT with NIHSS<6. Although it might be reasonable, the benefits are uncertain and effectiveness not established. Minor-mild stroke is not a benign condition and when there is a LVO the risks of early neurological deterioration and bad outcome are higher. Several studies have reported that reperfusion with MT strongly impacts the functional outcome among minor-mild stroke patients with LVO. But some of these studies lack control groups undergoing best medical treatment (BMT). Even though the complication rate in EVT is low, the clinical benefit has to outperform the cost and risks. And there are non-negligible risks of haemorrhage, vasospasm, stroke to distal/other territory, air-emboli or puncture complications. We can perform EVT in patients with LVO and low NIHSS! But do we need to? Should we do it outside a RCT? A multicentre-cohort-study comparing urgent MT associated with BMT versus BMT first and MT if worsening occurs, achieved excellent and favourable outcomes at 3 months in similar proportions. Another observational-multicentre-study in 170 patients with NIHSS?4 showed that BMT alone led to a 77% of excellent outcome. A systematic-review/meta-analysis from 2018, to determine if MT can benefit patients with LVO and mild stroke, included 5 studies with a total of 413 cases. When compared with BMT without tPA, MT and BMT with tPA were associated with improved outcome. However, there was no significant difference between MT and BMT with tPA. All these questions should prompt a RCT of primary versus deterioration-driven/rescue MT versus BMT including thrombolysis in patients with minor stroke and LVO.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):D3

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Debate


Should we treat distal occlusions with EVT? - read full article

By: J.M. Macho and Angel A. Marin-Suárez

Most of the Guidelines recommend endovascular recanalization in patients with acute ischemic stroke due to large vessel occlusions up until 6 hours after symptom onset, considering large vessel occlusion distal internal carotid artery (ICA), or proximal Middle Cerebral Artery (MCA), M1. Before the randomized trials, in 2014, several studies have shown that distal occlusions were more benign in their spontaneous evolution, without any recanalization treatment, than large vessel occlusions, and that patients with initial NIHSS ?8 and distal occlusion had good clinical outcome, independently of recanalization status. Some other studies comparing mechanical thrombectomy and i.v. thrombolysis, in the periphery of the M2 region, have shown that i.v. thrombolysis alone was superior to endovascular treatment in achieving a good outcome. More recently, data from the first randomized trial of thrombolysis in patients with mild ischemic stroke and no clear disabling deficit (PRISMS trial) show no evidence of benefit of tissue plasminogen activator (tPA) and an increased risk for symptomatic intracerebral hemorrhage in this population. One of the possible reasons for that superiority of the conservative treatment in the distal occlusions, is that benign natural history, for the less symptomatic patients. A second reason could be the higher risk of complications pointed by several metanalysis compared to the large vessel occlusions treatment, more easily accessible and easy to navigate. This higher risk has been shown as much with stentrievers as with aspiration. While Metanalysis of randomized trials (HERMES collaboration) favoured endovascular treatment across all site of occlusions, the question of benefit with more distally located occlusions in the M2 MCA segment is only partially addressed because randomized trials had very few patients with more distally located occlusions in the M2 MCA and do not have enough power to fully confirm benefit or harm in these patients. We probably should avoid treat that patients with mild symptomatology and distal occlusion.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):D4

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Debate


Perfusion imaging mismatch: the redemption of penumbral imaging - read full article

By: Richard Leigh

Salvage of the ischemic penumbra has been the target of all acute ischemic stroke therapies. Although at the population level there is a time dependence for beneficial intervention, recent trials have been able to identify patients who benefit despite prolonged, or potentially independent of, time from onset. Using multi-modal imaging, the ischemic penumbra can be detected using the perfusion imaging mismatch. An alternate approach for selecting patients has been to use the mismatch between the severity clinical deficits and the size of the core infarct. Generally, a large imaging mismatch identifies patients who would benefit the most from reperfusion of the ischemic penumbra. However, in the DAWN trial, a larger clinical mismatch was associated with worse outcome. This calls into question how interchangeable these measures may be. The DAWN trial demonstrated that the clinical mismatch can be used to identify a population that benefits from intervention. However, the DAWN trial relied on an extreme clinical mismatch, including only those with a very small core and a substantial clinical deficit. The DEFUSE 3 trial, on the other hand, used a continuous measure of imaging mismatch that included 60% more patients than DAWN. Despite more inclusive selection criteria in DEFUSE 3, the benefit of treatment was essentially the same between the trials. Subgroup analysis of the patients in the DEFUSE 3 trial who would not have been eligible for the DAWN trial found a significant benefit to intervention. According to the recently presented results, patients selected according to the DEFUSE 3 criteria did not exhibit a time dependence on outcome. In summary, the perfusion imaging mismatch, when used to identify a target profile (that was developed through an elegant series of observational studies), has now been shown to be the most successful methodology for identifying patients who will benefit from endovascular therapy.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):D1

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Oral Presentation


Bilateral carotid occlusive disease with inefficient collateral circulation—what now? - read full article

By: Cristina Ionel, Joana Morgado, Ana Ribeiro, Liliana Pereira, and Miguel Rodrigues

Background: Atherosclerotic bilateral carotid occlusive disease is an uncommon but potentially devastating condition, with increased risk of stroke and mortality. 
Objective: To discuss the management of symptomatic bilateral carotid occlusion. 
Case report: A 69-year-old male, with vascular risk factors, presented with a two-week-history of generalized muscle weakness resulting in gait loss and several syncope. On examination, there was evidence of left homonymous hemianopia, left upper neuron facial palsy and tetraparesis with left-sided predominant weakness. Urgent CT scan, CT angiography and cervical duplex ultrasound were performed. No acute ischemic lesions were identified, but the following was found: bilateral atherosclerotic occlusion of the right common carotid artery (CCA) and proximal left internal carotid artery (ICA); left vertebral artery hypoplasia, ending at the posterior inferior cerebellar artery; fetal pattern of the right posterior cerebral artery (PCA). The patient was hospitalized for further investigation. Transcranial Doppler showed reduced flow velocities in all vessels except in the left PCA. Bilateral hemispheric acute ischemic lesions on junctional vascular territories were found on MRI and SPECT demonstrated hypoperfusion of the right cerebral hemisphere. Cerebral angiography confirmed the previous findings, identifying anastomotic circulation, but not a good donor vessel for bypass surgery. After multidisciplinary discussion, an optimized medical management was decided. 
Conclusion: We present a case of symptomatic atherosclerotic bilateral carotid occlusion with ineffective collateral circulation. The best therapeutic approach to this condition remains unclear, and an individualized decision by a multidisciplinary team should be considered.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):O1

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Oral Presentation


Bilateral spontaneous internal carotid artery dissection with severe cerebral perfusion deficit: early management - read full article

By: Miguel Quintas Neves, Inês Carvalho, José Manuel Amorim, Eduardo Freitas, Octávia Costa, Raquel Carvalho, João Pinho, Carla Ferreira, and Jaime Rocha

A 59-year-old male was admitted in the emergency department with a one-week history of headaches, asthenia and inadequate speech. A pacemaker was implanted the previous month for nodal sinus disease. Neurological examination revealed encephalopathy, disorientation, inadequate speech and limitation of horizontal gaze. No lesions were visualized on brain computed tomography (CT) and CT angiography (CTA). Blood and cerebrospinal fluid analyses and electroencephalogram were unremarkable. Brain magnetic resonance imaging (MRI) showed recent bilateral ischemic lesions in watershed territories of anterior circulation. Magnetic resonance angiography (MRA) showed slow flow of all anterior circulation territory and magnetic resonance perfusion (MRP) confirmed a perfusion deficit. CT/CTA re-evaluation was consistent with bilateral dissection of both internal carotid arteries (ICA). Coma and decerebrate posturing occurred which did not resolve after induced hypertension. Left ICA revascularization with stenting and angioplasty was achieved. Right ICA treatment was unsuccessful but right middle cerebral artery collateral flow was observed. Follow-up brain MRI showed bilateral ischemic lesions in deep watershed territories. After neurointensive care a neurological improvement occurred. After a month, the patient is oriented, with preserved language function, and presents dysarthria and left hemiparesis (upper limb grade 3, lower limb grade 4). We report a rare case of spontaneous bilateral ICA dissection, with neurological manifestations consistent with cerebral hypoperfusion. Carotid dissection identification and cerebral perfusion deficits evaluation are essential to manage supportive treatment and identify patients who benefit from emergent endovascular carotid revascularization.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):O2

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Oral Presentation


Is the posterior cerebral artery worth endovascular treatment? - read full article

By: Teresa P. Morais, Catarina Perry da Câmara, Carolina Pinheiro, Isabel Fragata, Patrícia Ferreira, Ana Paiva Nunes, and João Reis

Background: Between 5% and 10% of all acute ischemic strokes occur in the posterior cerebral artery (PCA) territory. Endovascular treatment (EVT) in small vessels like PCA is still controversial regarding efficacy and safety.
Results: We report a case of a 87-year-old man with previous history of carotid endarterectomy, ischemic heart disease and atrial fibrillation, treated with dabigatran, who presented at ER with persisting feeling of being unwell for 2h. Neurologic examination revealed deviation of the eyes and head to the right, left homonymous hemianopsia, a left central facial palsy, dysarthria, left superior limb plegia and left inferior limb paresis and left sided hemihypoesthesia, scoring 15 points in NIHSS. Computed tomography (CT) showed no signs of acute lesion and CT-angiography revealed right PCA P1 occlusion. MRI was contraindicated due to cardiac pacemaker. There was an absolute contraindication for the use of t-PA because the patient was under anticoagulation, so after multidisciplinary discussion we opted for emergent endovascular clot aspiration. A TICI 3 was obtained in the end of the procedure (294 minutes after symptoms), with no complications. The 24h-control CT showed a hypodense lesion in the right lenticular nucleus, the posterior limb of the internal capsule and the right anterior thalamus. The patient was discharged 10 days after the intervention, with slight gait disturbance, scoring 1 point in NIHSS and a mRS of 1. Assuming this was a cardioembolic stroke we decided to switch the anticoagulant to apixaban 2,5mg, 2id, due to age over 80 years and weight under 60 kg.
Conclusions: PCA occlusion may present with significant neurologic disability. EVT is useful for acute PCA occlusion and might improve outcome in selected patients.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):O3

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Oral Presentation


Beyond the edge of DAWN - read full article

By: Leandro M. Marques, Miguel Quintas Neves, João Pinho, Carla Ferreira, and Álvaro Machado

Introduction: The DAWN trial proved the benefit of mechanical thrombectomy in patients with anterior circulation large-vessel occlusion stroke 6 to 24 hours (h) from symptom onset, with mismatch between the severity of the clinical deficit and the infarct volume, compared with the standard care.
Clinical Case: We present a 76 years old woman, with previous history of osteoporosis and angina; medicated with alendronate 70mg/week and bisoprolol 5mg/day. The patient was admitted for a left motor deficit after woke up (last seen well [LSW] at 11 pm). Vital signs were normal and there was a left hemiparesis, left central facial palsy, left homonymous hemianopsia, and anosognosia. Electrocardiography showed sinus rhythm. In the brain CT (LSW 27 h), there were no signs of acute ischemia or hemorrhage, and there was a hyperdensity in the top of the right internal carotid artery (rICA) and right middle cerebral artery (rMCA). A new brain CT was performed (LSW 36 h), with a striatal capsular and insular hypodensity, and a hyperdensity of the rICA and rMCA. Because of the mismatch between the severity of the clinical deficit and the infarct volume, a CT angiography and a brain MRI were performed (LSW 37 h), that revealed an arterial occlusion at the top of the rICA and M1 of the rMCA, and a recent ischemic lesion in the right corona radiate and striatum, respectively. At this point we would like to discuss with the experts the best management in this case: start antithrombotic therapy; perform thrombolysis; perform mechanical thrombectomy.
Conclusion: The DAWN trail proved that it’s beneficial the expansion of the time window to treat, when there is brain tissue to save, but only up to 24 h. We bring a case that meet the same criteria, but long after the proved time limit.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):O4

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Oral Presentation


Multimodal approach in current acute stroke therapy - read full article

By: Ricardo Varela, Daniela Vieira, Cristina Machado, César Nunes, Ricardo Veiga, Egídio Machado, Fernando Silva, João Sargento-Freitas, and Gustavo Santo

Background: Interhospitalar transfer after use of intravenous tissue-type plasminogen activator (tPA) in acute stroke is increasingly frequent. Intra-arterial stroke therapy is progressively challenging demanding an intricated medical and interventional articulation.
Clinical Case: Male patient, 61 yo, mRS 0, with previous history of active smoking, unmedicated hypertension and chronic alcoholism, admitted in a secondary center ER department with a left TACS within 30 min of evolution and scoring 22 in the NIHSS. Workup with head CT and angiogram revealed an ASPECTS of 10 and an occlusion in the M1 segment of the left middle cerebral artery. After interhospitalar stroke protocol activation, the patient initiated tPA (50 min) and was emergently transferred to our center entering the angio-suite after 130 min. Angiography revealed a left internal carotid subocclusive stenosis in addition to the previously identified M1 occlusion. After passing the stenosis, a TICI2b score was achieved using an aspiration device. In the face of early filling delay, it was decided for balloon carotid angioplasty which was successful despite secondary distal embolization determining another aspiration procedure resulting in a final TICI2b score. The patient was submitted to delayed internal carotid stenting after effective antiaggregation at the 10th day, with a final 40% stenosis. No clinical or imagological complications followed the procedures and the patient improved during admission, being discharged after 2 weeks with a NIHSS of 6 and a mRS of 3.
Conclusions: Current acute stroke therapy is quite challenging and demands an effective and organized articulation between the different centers and professionals. The controversy regarding the best clinical approach to tandem pathology is also addressed, further emphasizing the clinical differentiation need in the field.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):O5

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Oral Presentation


Carotid stent infection—what else could we do? - read full article

By: Marina Boticário, Sofia Galego, Patrícia Ferreira, Rui Carvalho, Isabel Fragata, and Ana Paiva Nunes

A 61-year-old man with prior history of atrial fibrillation, diabetes with poor metabolic control, hypertension, ischemic heart disease and peripheral arterial occlusive disease, underwent carotid artery stent (CAS) of left internal carotid artery. Five months after CAS he presented a left anterior circulation stroke syndrome (NIHSS 19) and was admitted at the hospital. Brain CT showed a left frontal operculum cortico-subcortical hypodensity. CT angiography revealed left carotid artery stent occlusion and a large intrastent pseudoaneurysm. Radiologic findings were corroborated by cerebral angiography, so coil embolization of pseudoaneurysm and a new stenting procedure in the left internal carotid artery was performed. Upon admission, the patient presented a high fever, blood cultures showed the presence of methicillin-resistant Staphylococcus aureus and vancomycin was initiated. Cerebrospinal fluid had a white blood cell count of 427/mL (60% polymorphonuclear neutrophils), a protein level of 194mg/dL and a glucose level of 23% of serum glucose. Infective endocarditis with septic meningoencephalitis was suspected and gentamicin was initiated; however, a transoesophageal echocardiogram excluded vegetations. Neck CT and MRI, performed 12 and 17 days after admission, demonstrated inflammatory changes of the pseudoaneurysm formation. Despite adequate antibiotic therapy the infection could not be controlled and the patient died. Infection involving endovascular devices are rare, particularly those associated with a carotid artery stent.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):O6

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Oral Presentation


Low aspects and malignant cerebral infarction—a silver lining? - read full article

By: Daniela Marto, Patrícia Ferreira, Sofia Galego, Bruno Maia, and Ana Paiva Nunes

A 44-year-old woman, with no past medical history, was admitted to the emergency department with altered level of consciousness and language impairment, last known to be well 11 hours earlier. At admission she was aphasic, with left-sided gaze deviation, had right homonymous hemianopsia, right central facial palsy, right hemiparesis and ipsilateral hyposthesia (NIHSS 22). A brain computerized tomography (CT) showed a hypodensity in the left middle cerebral artery (LMCA) territory (ASPECTS 3/4). A CT angiography revealed left internal carotid artery (LICA) and left middle cerebral artery (LMCA) occlusion. IV tPA treatment was withheld, and despite a low ASPECTS score, endovascular treatment was performed. Cerebral angiography showed LICA occlusive dissection and mechanical thrombectomy and balloon angioplasty was performed, achieving a TICI score 2c with a residual stenosis of 50%. Twenty-four hours after admission her neurological symptoms worsened and a brain CT was repeated, revealing an established ischemic lesion involving the LMCA territory with small petechial intralesional hemorrhage and cerebral oedema, conditioning a subfalcial herniation. She was started on osmotheraphy immediately. Clinical and radiological deterioration persisted, and after 72 hours she underwent decompressive craniectomy. The procedure was unremarkable and over the next following days progressive neurological improvement was seen. Three weeks after stroke, the clinical picture was essentially dominated by an anterior aphasia (NIHSS 11).

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):O7

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Oral Presentation


Recurrent intracerebral haemorrhage—a diagnostic challenge - read full article

By: Filipe Godinho, Joana Parra, Soraia Vaz, Margarida Dias, and Manuel Manita

Background: Lobar intracerebral haemorrhage may be due to various causes but often etiology remains undetermined.
Case Report: a 56-year-old woman, with prior medical history of Hashimoto’s thyroiditis and alopecia areata, was admitted to the emergency department with a 3-day history of a right-sided thunderclap headache, nausea and vomiting. She had had a total of 15 mg zolmitriptane during this period. Head CT and MRI studies showed a right parieto-occipital intracerebral haemorrhage (ICH) and a left frontal subarachnoid haemorrhage (SAH). Angiogram revealed multiple areas of segmental narrowing involving branches of the left posterior cerebral artery (PCA), both middle cerebral arteries (MCA) and both anterior cerebral arteries (PCA). She started on nimodipine 60 mg/day and a 5-day course of methylprednisolone (MP) and 11 days later the angiogram showed partial reversion of the segmental stenosis. She was discharged with a possible diagnosis of reversible vasoconstriction cerebral syndrome (RVCS), medicated with nimodipine. Two months later she had a new episode of bilateral frontal-temporal thunderclap headache precipitated by Valsalva maneuver. On admission, neurologic exam was normal. This time there was no recent history of triptans ingestion. Head CT and MRI showed a right frontal ICH and a right superior frontal sulcus SAH, with no white matter changes. Angiogram revealed focal stenosis of intracranial arteries, mainly MCA (bilaterally) and left ACA. Cerebrospinal fluid (CSF) examination was unremarkable and autoimmune serology was only positive for thyroid antibodies. The headache resolved after a 5-day course of MP and she was discharged with corticosteroid therapy.
Conclusions: Diagnosis of primary angiitis of the CNS (PACNS) should be considered in the presence of the CSF, MRI and angiogram findings, in the absence of serologic or clinical evidence of systemic vasculitis. However, RVCS cannot be ruled out, considering the clinical course and the more frequent association with haemorrhage. In fact, RCVS is considered one of the most common angiographic mimics of PACNS.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):O8

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Poster


CADASIL—an underestimated stroke’s cause - read full article

By: Joana Pereira and João Abrantes

Background: Stroke is one of the major causes of death and morbidity. Besides the common sporadic forms related to age, hypertension and atherosclerosis, a minority has a genetic cause, being the most common Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy—CADASIL, caused by mutations in NOTCH3 gene. The diagnose, done in 2-5 in each 100.000, is largely underestimated.
Objectives: This study aims to elucidate the clinical entity CADASIL, highlighting the warning signs that should motivate a more in-depth study and a screening of it.
Methods: Review studies found in Pubmed, between 2013 and 2018 under the keyword “CADASIL” with free full access to the article were considered, 7 were selected.
Results: CADASIL leads primary to migraines followed by premature onset of small vessel ischemic disease, resulting in vascular dementia, depression, behavioural changes, progressive cognitive impairment and acute encephalopathy. There’s no generally accepted diagnostic criteria, but a CADASIL score has been proposed by Pescini et al. that may help confirming the clinical suspicion. Magnetic resonance imaging appearance is characteristic with white matter hyperintensities in the anterior temporal lobe and lacunar infarcts which are an important predictor of cognitive impairment. Definitive diagnosis is given by genetic testing or a skin biopsy. An effective treatment is not available, but the control of vascular risk factors is an important part of CADASIL management.
Conclusions: CADASIL is an underdiagnosed condition that leads to premature and severe morbidity, with characteristic clinical and imagiological findings that should alert the physician to such diagnose, in order to identify individuals at risk and their relatives.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):P1

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Poster


Unexpected outcome in acute basilar occlusion - read full article

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

Background: Basilar occlusion is associated with poor clinical outcome, even when treated with mechanical thrombectomy (MT).
Methods: We present a case of non-successful acute basilar thrombectomy with good outcome.
Results: We report a case of an 86-year-old man, with hypertension, ischemic heart disease and dyslipidaemia. He presented to the emergency room with post-syncope nausea, vomiting, dysarthria and right hemiparesis. Neurological examination revealed left sixth cranial nerve palsy, right central facial palsy, right dysmetria, dysarthria and right Babinski sign. No acute lesion was noticeable on CT, but the angio-CT showed an occlusion of the distal third of the basilar artery. There was a diffusion/FLAIR mismatch on the MRI, with right lateral and left paramedian pontine lesions with restricted diffusion, without significant repercussion on FLAIR. MT by femoral and brachial access confirmed basilar occlusion with retrograde filling of both posterior cerebral arteries through posterior communicating arteries, suggesting collateral circulation in the setting of chronic stenosis. Thrombectomy was not possible due to severe tortuosity of cervical vessels. Despite the failed treatment with TICI 0, the patient improved and was transferred four days after with a NIHSS of 5, displaying only right flattened nasolabial fold, leg and arm motor drift, and arm ataxia.
Conclusion: Mechanical thrombectomy has good recanalization rate and favourable outcomes in basilar occlusion. However, in occlusion in the setting of chronic stenosis of the basilar artery, clinical outcome is better. In cases where distal access is difficult, it might be reasonable to avoid complications and halt endovascular treatment.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):P2

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Carotid stenting: who should perform it? - read full article

By: Carolina Pinheiro, Catarina Perry da Câmara, Teresa P. Morais, Jaime Pamplona, Patrícia Ferreira, and Sofia Galego

A 75-year-old male patient was electively admitted to the Vascular Surgery department to undergo carotid artery angioplasty and stenting. He was under dual antiplatelet therapy with clopidogrel and acetylsalicylic acid for the last 6 days. The patient had history of left-hemisphere transient ischemic attack associated with left internal carotid artery stenosis, ischemic heart disease treated with percutaneous coronary intervention, hypertension, type 2 Diabetes Mellitus, chronic HBVB and psoriasis. The following day, cerebral angiography was performed with left internal carotid artery stenting followed by balloon angioplasty. Immediately after the procedure, the patient presented left arm paresis; a carotid ultrasound showed 75% stenosis. Stroke protocol was activated two hours after symptom onset. Initial observation revealed right superior limb paresis (NIHSS 2). Blood pressure was high - 185/90mmHg. The head CT showed no acute parenchymal lesions. Angio-CT of the supra-aortic vessels revealed a stent thrombosis. Blood pressure was treated and he received a bolus of intravenous fibrinolysis. A new cerebral digital subtraction angiography was performed, with a symptom-to-puncture time of 3h30, and an intrastent aspiration thrombectomy with a complete recanalization (TICI 3) was accomplished. The procedure lasted for 15 minutes, during which a eptifibatide bolus was administered. Fibrinolytic perfusion was not performed because during the stenting procedure 5000 units of heparin were administered. The patient had a neurological recovery with a NIHSS of 0 on the following day, and the carotid ultrasound showed stent’s patency. Control head CT revealed no intracranial acute lesions. The old question remains: carotid stenting, who should perform it? Is it for vascular surgeons or cardiologist to treat? Or should only interventional neuroradiologists do it, since large vessel occlusion ischemic stroke is a well-known complication?

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):P3

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Intracerebral hyperattenuation following mechanical thrombectomy—distinguishing haemorrhage from contrast staining on CT - read full article

By: Luís Rito Cruz, Mafalda Mendes Pinto, Inês Carreiro, and Cristina Moura

Background: Following mechanical recanalization of an acute intracranial vessel occlusion, intracerebral hyperattenuations (ICHAs) are frequently found on CT. They represent either blood or, more commonly, enhancement of contrast agent. Contrast staining of brain parenchyma is an incompletely understood imaging finding, with controversial pathophysiology and prognosis. Intracerebral haemorrhage (ICHs) has a high mortality rate, leads to a significant decrease in clinical status and requires a prompt diagnosis.
Objectives: 1. To understand the causes of ICHAs after endovascular therapy and their clinical importance; 2. To illustrate helpful CT features in the distinction between ICH and contrast staining; 3. To briefly discuss the current theorized mechanisms involved in intraparenchymal contrast staining.
Methods: We reviewed the literature in order to determine the main clinical features and imaging findings of ICHAs after intra-arterial treatment. We then searched our database in order to find, review and depict relevant clinical cases.
Results/Conclusion: With increasing use of endovascular reperfusion, recognition of intraparenchymal contrast staining from true haemorrhagic transformation can pose a challenging problem. Definite diagnosis often cannot be made at an early stage. Follow-up studies may be necessary, proving gradual resolution in case of contrast material staining, or an increased / stable aspect, in case of haemorrhage. Accurate interpretation is clinically significant for therapy adjustment.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):P4

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Raising a myxomatous question - read full article

By: Francisco Sousa, Marta Lopes, Luís Fontão, Joana Sequeira, Manuel Ribeiro, and José Mário Roriz

Introduction: Atrial myxomas are either sporadic (vast majority) or related to an autosomal dominant transmission, so called Carney’s Complex. Atrial myxomas may be associated with single or multiple cerebral aneurysms, possibly through an embolic mural invasion process. Although neurologic deficits in patients with intracardiac masses may first resemble embolic strokes, delayed neurologic events owing to aneurysms after surgical treatment may ensue. We present the case of an operated cardiac myxoma associated with a complex MCA fusiform aneurysm, aiming to discuss treatment options. 
Clinical Case: 53-year-old man with past history of a nevus removal and a cardiac myxoma interventioned 9 months before, presented to the ER with a first and self-limited generalized tonic-clonic seizure. Brain CT showed right parieto-occipital and left frontal hypodensities, highly suggestive of previous strokes, as well as a tortuous, dilated and hyperdense left MCA, without signs of subarachnoid hemorrhage. CTA confirmed the presence of large fusiform dysplastic left MCA aneurysm, involving the superior and inferior M2 divisions, as well as M3 segments. Conservative attitudes were adopted, with planned imagological follow-up. The patient reminded asymptomatic and seizure free for 1 month of follow-up, medicated with valproate sodium. 
Discussion: In the presented case, the etiology of the fusiform aneurysm should include considerations about the past existence of a cardiac myxoma. Most importantly, the morphology and location of the aneurysm and its unknown clinical relevance represent a challenge for treatment decisions - with unusual and technically demanding alternatives for interventional approach, despite the aneurism`s size and possible symptomatic debut.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):P5

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Intravenous and intraarterial thrombolysis: can we do it together? - read full article

By: Ana Bravo, Marisa Mariano, Sofia Galego, Patrícia Ferreira, Ana Paiva Nunes, and Isabel Fragata

A 38 years old woman, with no relevant past medical history, was admitted to the Emergency Department with dysartria, left flattened nasolabial fold and left hemiparesis (NIHSS: 8). Brain computed tomography (CT) revealed spontaneous hyperdensity in the M1 and M2 portions of the right middle cerebral artery (MCA), with early signs of ischemia (ASPECTS 8/9). Intravenous (IV) recombinant tissue plasminogen activator (rt-PA) (0.9 mg/kg) within 3 and half hours of onset of the symptoms was performed and referral to a tertiary center for mechanical thrombectomy. At arrival, five hours later, she underwent brain CT that showed ischemic lesion on the right temporal-insular region, lenticular and caudate nucleus (ASPECTS 6/7) and angio-CT revealed probable M2/M3 portions of the right MCA occlusion. Cerebral angiographic confirmed M3 (frontal-parietal branch) portion of the right MCA occlusion and intra-arterial (IA) rt-PA was performed with TICI 2c. Control brain CT showed infarcts of right temporal-insular, lenticular and caudate nucleus, with slight mass effect, with no hemorrhagic transformation. Transesophageal echocardiography study revealed an interauricular septal defect with patent foramen ovale and right-left shunt. The remain study was normal. She was discharge after 7 days with minor dysarthria, left facial central palsy and left hemiparesis – NIHSS 6. This case illustrates that, although the role of IA thrombolysis is not consensual, there may be a clinical benefit in patients with distal occlusions.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):P6

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Change in blood pressure profile after stroke - read full article

By: Ana Tornada, Paula Alcântara, Cristina Alcântara, and Carlos Moreira

Introduction: Stroke remains the leading cause of long-term disability and the second most common cause of death worldwide. Twenty-four-hour ambulatory blood pressure monitoring (ABPM) is proven to be a useful scientific method to predict blood pressure related brain damage. There is controversy in changes in BP profile in stroke patients. Our aim was to evaluate changes in circadian rhythm of blood pressure after a stroke.
Methods: Consecutive patients admitted for acute stroke that had performed an ABPM in the previous six months, with a normal nocturnal dipper pattern, and on the next 6 months. The ABPM device was placed on the patient's unaffected arm. Besides ABPM these patients had clinical examination and blood study. We used models of chi-square and t-student and accepted significant values of p <0.01 (two-tailed).
Results: We included 96 ischemic stroke patients, 94 (98%) with hypertension, 34 (35.4%) with diabetes, and 25 (25%) smokers. In 82 (85%) patients nocturnal “dip” was abolished (ND) and 36 patients (38%) displayed an "inverted-dipper" (ID) profile. Comparison of the two groups showed significant differences regarding pulse wave velocity (ND13,6 + 2.4 and ID 16.4 + 2.7, p<0.01) and augmentation index (ND 29.1 + 9.8 vs ID 24.6 + 8.6, p<0.01). There was also a significant difference between the asleep SBP (ID 108.2 + 10,4 versus ND 101.3 + 9.6, p<0.01) and asleep DBP (ID 59.2 + 6.2 versus 52.7 + 7.4, <0.01), regardless of other risk factors and history of hypertension.
Conclusion: The study detects a pathological alteration of blood pressure circadian profile after stroke occurrence, which may reflect severity in target organ damage. The ID had worse parameters than ND, which suggest that these patients may have a worse prognosis.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):P7

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Thrombectomy with stent retriever for thromboembolic complication after coil embolization of intracranial aneurysm - read full article

By: Luís Cardoso, Hugo M. Dória, Ricardo Martins, Luís Albuquerque, Ângelo Carneiro, and José Pedro R. Pereira

Introduction: Thromboembolic complication during coil embolization of intracranial aneurysms is a known concern, occurring in 2.5 to 28% of patients. Possible causes of thrombus formation are the presence of foreign materials, the electric current used for detachment of the coils and hypercoagulable state in the case of aneurysm rupture with subarachnoid haemorrhage. Wide-neck, large aneurysms or coil embolization with the balloon-assisted technique have been associated with higher rates of thromboembolism.
Case presentation: A 54-year-old woman with an unruptured wide-neck aneurysm of the right internal carotid artery (ICA) ophthalmic segment, performed an elective embolization with detachment of 6 platinum coils and balloon-assisted technique; 5000 units of heparin were intravenously administered after guide catheter positioning. Two hours later developed a left hemiparesis. On angiography, a non-occlusive thrombus was observed in the right ICA, from the aneurysm to the ICA bifurcation, and distal occlusion of a middle cerebral artery (MCA) branch. 10mg of glycoprotein IIb/IIIa inhibitor were injected in the ICA proximal to the thrombus, then rescue mechanical thrombectomy was attempted using a retrievable stent. Final controls showed residual thrombus next to the aneurysm neck with good anterograde flow and slower filling of small distal MCA branches (TICI 2b).
Conclusions: We report a successful case of mechanical thrombectomy with retrievable stent of a thrombus formed in the neck of the aneurysm and related to a coil mass. This stent retriever-based technique can be used as a rescue therapy, however the passage of the stent through the parent artery and close to the coiled aneurysm has rarely been reported and there are still few data on its efficacy and safety.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):P8

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Importance of sleep-time ambulatory blood pressure and pulse wave velocity as marker of stroke - read full article

By: Ana Tornada, Paula Alcântara, Cristina Alcântara, and Carlos Moreira

Introduction: Elevated blood pressure (BP) is a major risk factor for stroke and other cardiovascular and metabolic events. Many prospective ambulatory blood pressure monitoring (ABPM) studies demonstrate that elevated sleep-time BP constitutes a significant cardiovascular disease risk factor independent of the daytime ABPM or ambulatory awake and 24 h BP mean values. The aim of this study was to evaluate if these parameters were different before stroke (STK) in hypertensive patients compared to patients without stroke.
Methods: Patients admitted with stroke (WS), and who performed an ambulatory blood pressure measuring (ABPM) and pulse wave velocity (PWV) in the six months prior to stroke were compared with hypertensive patients without events (WOS). The 90207 monitor Spacelab was used for ABPM. PWV was evaluated with sphigmocor system. We used models of chi-square and t-student and it was considered significant values of p <0.01.
Results: The two groups of 50 patients had similar age, sex, risk factors, office blood pressure, and day ambulatory blood pressure. We found that night systolic (WS 116.9+10.6 vs WOS 104.8+11.2, p<0.01), diastolic (WS 71.3+7.1 vs WOS 66.8+8.4, p<0.01) and pulse pressure (WS 46,2+8.1 vs WOS 52.7+9.8, p<0.01) pulse wave velocity (WS 18.9 + 4.4 and WOS 13.7 + 5.3, p<0.01) and augmentation index (WS 22.3 + 12.7 vs WOS 30.2 + 11.8, p<0.01) are different in the two groups. We also detect a significant difference between both groups in % of dipper patients (WS 64% vs WOS 44%, p<0.01).
Conclusion: Hypertensive patients with stroke had higher night-time blood pressure than non-stroke patients and had more vascular damage measured by PWV and AI, independent of other common risk factors for stroke.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):P9

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Ischemic stroke in young adults—experience from a regional hospital - read full article

By: Marta Cerol, Natália Teixeira, Ana Mestre, Sónia Almeida, Rita Paulos, and Margarida Cabrita

Background: Ischemic stroke, though being less common in young than in older adults, is an important cause of disability in the former.
Objectives: To describe risk factors, etiology, treatment and prognosis of young patients with ischemic stroke.
Methods: Retrospective analysis of patients aged 55 years or younger hospitalized in the internal medicine ward with ischemic stroke from January 1st 2013 to December 31st 2016.
Results: The study included 31 patients, 74.2% were men, with a median age of 48 year. Most of the patients had at least one cardiovascular risk factor. Arterial hypertension was the most common risk factor (64.5%), followed by hypercholesterolemia and cigarette smoking (35.5% each) and diabetes mellitus (25.8%). The etiology of the ischemic stroke was as follows: atherotrombosis in 25.8%, lacunar stroke in 19.4%, cardioembolism in 16.1%, other determined causes in 19.3% (including nonatherosclerotic vasculopathies in 3.2%) and undetermined in 19.4%. All patients were discharged with an antiplatelet drug and 25.8% were also treated with an anticoagulant. None of the patients had a recurrent episode at 6 months, but one died of unrelated causes and three abandoned follow-up.
Conclusions: The majority of stroke events in the patients studied appear to be related with a high prevalence of classical cardiovascular risk factor, which should be targeted with specific health programs in order to reduce the morbidity and mortality associated with stroke in this population.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):P10

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Isolated MCA dissection: what to do in the angio suite? - read full article

By: Pedro Calvão-Pires, João Pedro Marto, Tiago Baptista, Miguel Viana-Baptista, and Gabriel Branco

Background: Ischemic stroke due to an isolated middle cerebral artery (MCA) dissection is rare. Currently there are no recommendations on how to treat these patients when mechanical thrombectomy is considered.
Methods: A 42-year-old male patient with history of hypertension presented to the emergency department with an acute two hour left-sided hemiparesis and speech impairment. At admission he was hypertensive and scored 12 points at the National Institutes of Health Stroke Scale. Computed tomography (CT) did not demonstrate any early ischemic area of infarcted tissue and the CT angiography showed a partial right MCA occlusion. Thrombolysis was performed with a symptom-to-needle time of 175 minutes. Patient was taken into the angio-suite and the digital subtraction angiography study disclosed a right M1 occlusion with associated filiform flow distally.
Results: The neurointerventionalist decided to conduct thrombectomy with an aspiration device. After a first attempt with an ameliorated distal flow, a second attempt was taken to achieve full recanalization. At this time, at the topography of the occlusion, a sharp vessel appearance was noted suggesting the presence of an arterial dissection. No further recanalization of the vessel was achieved. The patient developed a partial infarction of the right MCA territory, with no haemorrhagic complication. After a complete investigation, no other stroke aetiologies were found. Modified Rankin Scale at 3 months was 3.
Conclusion: We present a case of an ischemic stroke due to an isolated MCA dissection. This type of dissection can be challenging to manage in the acute setting, with scarce treatment possibilities.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):P11

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Fahr’s disease and stroke - read full article

By: Andreia Machado Ribeiro, Madalena Paulino, Ana Pidal, Ana Palricas, Socorro Piñeiro, and Alexandre Amaral e Silva

Background: Fahr’s disease (FD) is a rare neurodegenerative condition characterized by symmetric intracranial calcifications, mainly in basal ganglia and dentate nuclei of the cerebellum. Clinical manifestations may include movement disorders, dementia and behavioural symptoms.
Case report: A 53-year-old female with FD presented to emergency department with acute onset of speech disturbance. Neurological examination showed aphasia, right central facial palsy and right upper limb paresis, National Institutes of Health Stroke Scale (NIHSS)=4. She was admitted at our Stroke Unit and treated with Clopidogrel 75mg and Atorvastatin 20mg. Laboratory tests were normal, except for LDL 111 mg/dL. Electrocardiogram showed sinus rhythm. Cranial computed tomography demonstrated left cortical-subcortical frontotemporal hypodensity, suggesting acute ischemic vascular injury in the peripheral territory of the middle cerebral artery, and exuberant calcifications involving basal ganglia and thalamus (in accordance with diagnosis of FD). Carotid, vertebral and transcranial doppler ultrasound were normal, as well as transthoracic echocardiogram. At discharge she maintained minor right central facial palsy and gait imbalance, NIHSS=2, modified Rankin Scale=3. She was referred to continue her rehabilitation process in a rehabilitation centre. No other etiology was found for stroke in this patient, beyond the possible association to FD.
Conclusion: Some studies have proposed an association between young-onset ischemic stroke and FD. The calcium deposition in the intracranial blood vessels wall leads to a reduction of vessel elastance, thereby predisposing to ischemia. The evidence for the proposed association between FD and stroke is still scarce and further studies are needed.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):P12

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Acute ischemic stroke treatment in moyamoya syndrome - read full article

By: João Pedro Filipe, Ana Aires, Luís Braz, Luís Augusto, Rita Figueiredo, Tiago Parreira, Pedro Abreu, Luísa Fonseca, and Maria Luís Silva

Introduction: Patients with moyamoya syndrome were excluded from many endovascular reperfusion therapy (EVT) trials due to their increased hemorrhagic risk. Hence, EVT is controversial and typically avoided in those patients.
Case report: A 36-year-old woman with moyamoya syndrome secondary to radiotherapy for a craniopharyngioma presented with confusion at waking up, after having been seen well the night before. Admission brain CT depicted a “dense vessel sign” in the left ICA terminus, prompting CT Angiography and CT Perfusion which revealed a left “carotid T” occlusion and an area of penumbra in the left MCA territory. The last MRI available, performed in out-patient clinic, showed narrowing and absence of flow in the distal right ICA but presence of flow in the left ICA and in the circle of Willis. Due to the unknown stroke onset time and NIHSS of 1, IV tPA was not considered. Despite her low NIHSS while lying down, her clinical status worsened with slight orthostatism to NIHSS of 6, due to dysarthria and right hemiparesis. Mechanical thrombectomy was considered after multidisciplinary discussion. Angiographic characterization revealed occlusion of the left ICA C7 segment with leptomeningeal and transdural collaterals via the other main vessels. A distal access catheter was then advanced to the occlusion site and direct aspiration was performed multiple times, without success. The patient was then admitted in the stroke unit and antiplatelet therapy was started. At discharge she presented an NIHSS of 4 and she’s being considered for surgical treatment.
Conclusion: This case highlights the controversy concerning the safety and effectiveness of EVT in moyamoya syndrome. To our knowledge, only one case of successful EVT in such patients was reported so far.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):P13

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Young stroke—endovascular thrombectomy and outcomes in a single centre - read full article

By: F. Proença, M. Mendonça, F. Raposo, P. Teotónio, M.A. Correia, C. Guerreiro, J.B. Madureira, P. Sequeira, L. Biscoito, and L. Neto

Background/Objectives: Acute ischemic stroke in young patients has an enormous social impact, leaving victims incapacitate during their most productive years. One fourth of all strokes occur under the age of 65 and 1/10 are younger than 50. It is known that endovascular thrombectomy (EVT) improves the outcome of certain patients, however few studies focus on young adults. The aim of this study was to analyse the clinical, imaging, procedural characteristics and outcomes after EVT in adults aged<=50. 
Methods: In 2016/2017, 220 stroke patients were admitted for EVT in our department. From these, 29 young strokes were collected. Clinical, imaging, procedural data and outcome (modified Rankin Scale –mRS-at 90 days) were retrospectively reviewed. 
Results: There were 15 females and 14 males, with a median age of 42. More than 80% of the patients had at least one vascular risk factors, 34.5% being smokers. Twenty-six were anterior and 3 posterior-circulation occlusions, 76% achieving recanalization TICI=2b-3. After 3 months, 16 (55.17%) had a good (mRS 0-2) and 13 (44.83%) a poor outcome (mRS 3-6), 2 deaths. Baseline National Institutes of Health Stroke Scale (NIHSS) score, Alberta stroke programme early CT score (ASPECTS), use of intravenous thrombolysis, recanalization grades, devices and symptomatic intracerebral haemorrhage are presented for the good and poor outcome groups and possible correlations discussed. 
Conclusion: Stroke in young adults should be viewed as a different entity. Our analysis showed that although more than half of the patients had a good outcome there was an important rate of disability. There is a lack of specific guidelines for stroke management in young adults and further research is needed for better prevention and reduction of morbi-mortality.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):P14

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Tandem occlusion stroke due to internal carotid artery dissection: choose your strategy - read full article

By: Gonçalo Alves, João Pedro Filipe, Francisca Costa, Rita Figueiredo, Paulo Castro Chaves, and Duarte Vieira

Introduction: Internal carotid artery dissection (ICD) is a major cause of stroke, mainly in young patients. Intracranial clot migration represents the most frequent cause. The medical approach is known to be sparse, with poor clinical outcomes regarding intravenous thrombolysis. Clinical deficits and Circle of Willis patency represent crucial criteria for endovascular management. The mechanical treatment of choice in ICD is under debate.
Case report: We present a 45 years-old male, admitted due to sudden left central facial palsy, dysarthria and numbness in the left hand. Four days before admission he had hemicranial headache followed by right palpebral ptosis. Neurological evaluation revealed right Horner Syndrome and a NIHSS of 2 (1 facial palsy and 1 dysarthria). Brain CT showed a hyperdensity on the right MCA, with ASPECTS 10 and CT perfusion with an area of increased MTT and decreased CBF (with normal CBV) in this territory. CT angiography was suspicious for right ICD. DSA confirmed the dissection, a thrombus near the right MCA bifurcation and collateral flow through the ACoA. Mechanical thrombectomy with stent-retriever was performed with a TICI 2b revascularization. He progressed with a NIHSS of 1, without new clinical deficits. The extended blood workup was negative. He started single antiplatelet therapy. Brain MRI two days later showed small cortical infarcts in right parietal and temporal lobes.
Discussion: This clinical case illustrates the challenges of tandem stroke related to ICD. The decision to move for an endovascular approach was made, despite the poor NIHSS, due to evidence of acute intracranial thrombus. Endovascular mechanical thrombectomy was effective and the good collateral pathways moved us away from stent placement in the acute phase.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):P15

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Clinical and imagiological dissociation in acute ischemic stroke - read full article

By: José Beato-Coelho, Bruno Silva, Ricardo Varela, Fernando Silva, Gustavo Cordeiro, and João Sargento-Freitas

Introduction: The NIHSS represents a fast evaluation of patients with acute ischemic stroke. A NIHSS of more than 11 has a positive predictive value for proximal occlusion of 81%. Yet an apparent minor stroke with low NIHSS does not exclude a proximal occlusion. Correctly identifying patients with acute ischemic stroke who might benefit from reperfusion treatment is crucial.
Case report: A 68 years old male patient presented to the emergency room of a level B Stroke Unit Hospital with a 2-hour evolution Broca aphasia. He performed brain CT who had an ASPECTS of 10. He started endovascular fibrinolysis and performed a cerebral Angio-CT who revealed an M1 left middle cerebral artery (CMA) occlusion. He was transferred to a tertiary hospital. At arriving he had only a central right facial paresis – NIHSS 1. It was decided to repeat the angio-CT with cervical evaluation which revealed the maintenance of the M1 occlusion and a sub-occlusion of the left internal carotid artery (ICA). Endovascular thrombectomy was performed with a final TICI of 3. Two days later after cerebral control CT with no vascular lesion a carotid stenting was performed. A female patient with 65 years old who came to our emergency department with a one-hour evolution left hemiparesis G4+. The NIHSS at entrance was 3 with no cortical deficits. In the cerebral CT there was only a spontaneous hyperdensity in the right CMA. We performed a cervical and cerebral angio CT which revealed a right ICA sub-occlusion and a right M1 occlusion. She started intravenous fibrinolysis and went to endovascular thrombectomy, but a reperfusion was not possible.
Conclusion: These two cases represent the challenge of identifying proximal occlusion in patients with minor deficits. NIHSS should not guide us to define which patients should do a cerebral vascular evaluation.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):P16

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Ischemic strokes with low NIHSS scores what to do? - read full article

By: Rui Osório, Patricia Ferreira, Marisa Mariano, and Ana Paiva Nunes

A 40-year-old male, past medical history of hypertension, dyslipidemia, ST elevation myocardial infarction, intraventricular thrombus (2 years ago, with acenocumarol) and chronic Hepatitis B, presented to the emergency department with left side weakness and slurred speech. In the admission, dysarthria, flattened left nasolabial fold and left side hemiparesis (NIHSS 3) were observed. Cranial computerized tomography (CT) scan revealed no acute ischemic lesions and the angio-CT showed occlusion of M1 segment of right middle cerebral artery (RMCA), with good collateral circulation. After a thorough discussion, weighing the benefits and risks in a young patient with neurologic deficits, with an M1 RMCA occlusion, low NIHSS score and INR 1, fibrinolytic therapy was performed and the patient was transferred to our hospital. At arrival, a neurological deterioration with NIHSS 8 due to partial gaze palsy, complete hemianopia, partial facial weakness, left side hemiparesis, left hypoesthesia, dysarthria. Mechanical thrombectomy was performed with complete perfusion (TICI 3). Magnetic resonance showed multiple small ischemic lesions in deep and superficial territories of the RMCA. Transthoracic echocardiography revealed no intraventricular thrombus and no major structural changes. The transesophageal echocardiography found no intraventricular thrombus but revealed altered segmental myocardial contractility. The patient was discharged with no neurologic symptoms. It was assumed ischemic stroke of undetermined etiology, however due to a strong cardioembolic suspicion hypocoagulation was re-introduced. Low NHISS: should we treat immediately or wait for a deterioration?

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):P17

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Does thrombus density correlate with the number of retrieval attempts in anterior circulation thromboembolic stroke? - read full article

By: J.B. Madureira, C. Guerreiro, M. Mendonça, P. Teotónio, F. Proença, M.A. Correia, F. Raposo, L. Neto, P. Sequeira, and L. Biscoito

Background/Purpose: An association between tomographic thrombus density (TD) and thrombectomy reperfusion result has been reported, although the reasons are not fully understood. Frequently, several thrombectomy attempts are necessary to restore revascularization. The aim of this study was to evaluate if there is a correlation between TD and the number of stent retrieval attempts (NRA).
Methods: A retrospective analysis of all thrombectomies performed at North Lisbon Hospital Centre from January 2016 to February 2018 was conducted. Only M1 or terminal internal carotid occlusion strokes were included. Procedures using aspiration devices and cases without non-enhanced CT scan and/or CT-Angio were excluded. TD was analysed by two independent neuroradiologists, blinded for the NRA. TD was calculated as a ratio between the Hounsfield Units of the most hyperdense area of the thrombus and the corresponding contralateral arterial segment. Data concerning TD, Thrombolysis in Cerebral Infarction (TICI) scores, NRA and procedure times were analysed.
Results: From a total of 231 thrombectomies, 57 procedures were selected. Median age was 74 years (range: 42-93). rtPA was administered in 59,6% of patients. TICI scores were: 0-2a n=13; 2b-3 n=44. The median NRA was 2 (range: 1-9). No statistically significant correlation between NRA and TD was found (p>.05), even after adjusting for the use of rtPA, age and procedural times. TICI scores and TD were statistically associated (p<.05), as were TICI scores and NRA (p<.05).
Conclusion: The use of TD as a predictor of NRA could not be established. The NRA may be influenced by other factors not analysed in this study (e.g. thrombus length, etiology and retrieval technique), thus requiring further research.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):P18

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A horse with stripes—the importance of clinical-radiological correlation - read full article

By: Hugo Dória, Luís Cardoso, Ricardo Martins, Ângelo Carneiro, and João Xavier

Introduction: Increasing evidence favours the benefits of thrombectomy and amidst its growing practice, proper clinical assessment and successful bridging between specialties is as important as ever.
Case report: A 79-year old male with modified Rankin Scale of 0, multiple vascular risk factors, ischemic cardiopathy, history of acute myocardial infarction (AMI), heart failure, peripheral artery disease and implantable cardioverter defibrillator was admitted after acute pulmonary oedema following cardiogenic shock secondary to another AMI. Cardiac catheterization was performed, during which he reportedly went into coma. The patient was rushed to the emergency department and the possibility of vertebrobasilar insufficiency prompted a cerebral CT scan, without proper neurological assessment. The CT scan showed no signs of cerebral infarction. There was, however, increased mean transit time in the area supplied by the right middle cerebral artery (MCA) with corresponding "arterial stop" sign on its M1 segment. Neurological examination done afterwards revealed fluctuations of awareness and tetraparesis with right-sided dominance. Despite clinical-radiological mismatch, the patient was nonetheless taken for thrombectomy. Angiography revealed several irregularities along the internal carotid and vertebral arteries, as well as what ended up being a chronic stenosis in the M1 segment of the MCA with local neovascularization and collateral flow via posterior circulation. No further endovascular action was performed.
Conclusion: We present the case of a seemingly classical thrombectomy candidate, except it lacked the most important variable - clinical reasoning. Teamwork between specialties and joint effort in assessing the context should always be a premise in medical care.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):P19

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Poster


Thrombus aspiration vs stent retriever for anterior circulation in ischemic stroke: retrospective review of the technique efficacy - read full article

By: M. Mendonça, J.B. Madureira, C. Guerreiro, P. Teotónio, F. Proença, M.A. Correia, F. Raposo, G. Basílio, L. Neto, and L. Biscoito

Background/Objective: Endovascular thrombectomy in patients with ischemic stroke caused by large vessel occlusion (LVOs) has emerged as superior to standard medical therapy. The purpose of this study was to compare the procedural efficacy of thrombus aspiration (TA) vs stent retriever (SR) technique among patients with LVOs of the anterior circulation.
Methods: Retrospective analysis of all thrombectomies (n=231) performed at North Lisbon Hospital Centre from January 2016 to February 2018 was made. Medial cerebral artery (MCA) M1 segment/terminal internal carotid (IC) occlusions that performed SR or TA technique were selected. Data concerning Thrombolysis in Cerebral Infarction (TICI) scores and procedure times (groin puncture to recanalization) were analyzed. Success of the thrombectomy was defined as TICI > 2b.
Results: From a total of 231 thrombectomies, 116 patients were treated for occlusions of MCA M1 segment/ terminal IC. Among these, 64 patients underwent primary SR and 52 primary TA therapy. In the first group, median procedure time was 63 minutes (minimum 15`; maximum 183`) and successful revascularization (TICI >2b) was possible in 73.4% (n=47). In the TA group the median procedure time was 44 minutes (minimum 27`; maximum 113`), and successful recanalization was 48% (n=25), but considering that 27 patients had to do the association with the stent retriever technique.
Conclusion: Among patients with ischemic stroke in the anterior circulation undergoing thrombectomy, primary TA technique compared with SR resulted in shorter procedure times, although in almost half the cases an association with stent was necessary.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):P20

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Poster


TICI 2B versus TICI 3 reperfusion: what is its prognostic value? Should there be a place for TICI 2C? - read full article

By: F. Raposo, F. Proença, M.A. Correia, C. Guerreiro, M. Mendonça, P. Teotónio, J.B. Madureira, P. Sequeira, L. Biscoito, and L. Neto

Background: Thrombolysis in cerebral infarction (TICI) grade is the most applied classification to assess reperfusion in patients treated with thrombectomy (EVT) for acute ischemic stroke (AIS), grades 2B/3 considered successful reperfusion. However, with this scale, a wide range of patients is included in a single category, despite heterogeneous angiographic outcome. TICI2B score does not differentiate between 51% or nearly total perfusion and this difference could relate to outcome of patients.
Objective: To compare the clinical outcome of patients that underwent EVT for AIS, according to its recanalization grade TICI 2B or TICI 3. To evaluate the relevance of adding an intermediate class 2C in the prognosis of the 2B class.
Methods: Registries of 220 patients who underwent EVT in our center in 2016-2017 were reviewed, and 128 TICI 2B/3 patients included. Clinical outcome was measured as ?NIHSS (pre-treatment vs discharge) and modified ranking scale (mRS) at 90 days. Two subgroups were established based on pre-treatment CT scan: ASPECTS>=8/ASPECTS<8. Clinical outcome of TICI 2B (67) vs 3 (61) was compared in subgroups. Afterwards TICI 2B patients were subdivided into 2B (40) and 2C (27) groups, the last defined as distal vessel occlusions/near complete reperfusion. TICI 2Bvs2Cvs3 outcomes were then compared.
Results: TICI 3 patients had superior short (?NIHSS) and mid-term (mRS) clinical outcome compared to TICI2B, mainly in the ASPECTS >=8 subgroup. There were no statistical significant differences between groups after subdividing 2B into a 2C class.
Conclusions: A combination of a higher pre-treatment ASPECTS score and a TICI 3 was associated with a better clinical outcome. When comparing the clinical outcome of TICI2Bvs2Cvs3 groups, no statistical significance was achieved, although we acknowledge that the small size of the 2C group was a limitation for this analysis.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):P21

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Poster


Posterior circulation ischemic stroke trombectomy—outcome of a single centre 24 months experience - read full article

By: M. Mendonça, M.A. Correia, F. Proença, P. Teotónio, F. Raposo, C. Guerreiro, J.B. Madureira, L. Neto, L. Biscoito, and P. Sequeira

Background and Objective: The natural history of posterior circulation (PC) artery occlusion is devastating, with morbidity rates increasing up to 80%. Early recanalization seems to be associated with better clinical outcomes; however, the best management is still uncertain. The aim of this study was to investigate the outcome of acute-phase thrombectomy involving PC.
Methods: From January 2016 to January 2018, 215 patients were admitted for endovascular treatment at our centre. We selected the ones who underwent thrombectomy for acute stroke involving PC, and retrospectively reviewed clinical and angiographic records to investigate the outcome. Thrombectomy success was defined as Thrombolysis in Cerebral Infarction (TICI) ? 2b, and good clinical outcome as a value in the modified Rankin Scale at 90 days (mRS) <= 3.
Results: A total of 19 patients were treated with thrombectomy for acute ischemic stroke involving PC. The median age was 68.11 years and 62.48% of the patients were male. The mean initial NIHSS on admission was 18.4. The occlusion sites included the vertebral artery (VA) (n=1), basilar artery (BA) (n=16), VA and BA (n=1), and posterior cerebral artery (n=1). Successful recanalization (TICI ? 2b) was possible in 16 of 19 patients (84%). At 3 months, 47% of the patients had mRS <= 3 (good to moderate clinical outcome), 37% had mRS 4-5 (poor clinical outcome), and 16% had mRS = 6 (dead).
Conclusion: Mechanical thrombectomy for the ischemic stroke of the PC was found to be associated with successful recanalization. We also observed favourable clinical outcome in a high percentage of these patients.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):P22

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Poster


How old are you? Clinical outcome of mechanical thrombectomy in the elderly patients with acute ischaemic stroke - read full article

By: M.A. Correia, F. Raposo, J.B. Madureira, M. Mendonça, C. Guerreiro, F. Proença, P. Teotónio, L. Biscoito, P. Sequeira, and L. Neto

Background: Mechanical thrombectomy (MT) has proven to be an effective treatment for proximal occlusions of the major intracranial arteries in stroke patients, but there is only limited information as to whether there should be an age limit for its use. With the average life expectancy increasing worldwide, usually surpassing 80 years old, it remains uncertain whether MT is effective in this group of patients.
Objective: To evaluate the safety and efficacy of endovascular therapy in elderly adults treated for acute ischaemic stroke.
Methods: We retrospectively collected all the patients with >80 years old subjected to MT in our centre during 2016-17. We analysed success of recanalization (Thrombolysis In Cerebral lnfarction (TICI) >2b), neurological improvement (improvement of ?4 points on National Institutes of Health Stroke Scale (NIHSS)), favourable and moderate clinical outcome (modified Rankin Scale (mRS) score at 3 months ?2 and =3, respectively) and mortality.
Results: From a total of 220 patients that underwent MT in our centre, we selected 57 patients with 84 ± 3.4 years old. The mean NIHSS on presentation was 17.8±5.52 and 11.4±7.6 post thrombectomy, with neurological improvement present in 65.5%. The success of recanalization was reached in 78.9% of the patients, favourable clinical outcome was achieved in 33.3% and moderate outcome in 24.6%. The mortality rate was 10.5%.
Conclusions: Clinical independence was reached in a significant number of patients, and an additional important group was able to walk without assistance. This total of 57.9% shows that, even if associated with higher morbidity and mortality, MT is a treatment option very viable when quality of life is the most important consideration for acute ischemic stroke in elderly patients.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):P23

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Poster


Imaging findings in cerebral air embolism after hyperbaric oxygen therapy treatment - read full article

By: Luís Cardoso, Ricardo Martins, Gonçalo Videira, Catarina Pinto, Rui Felgueiras, José Pedro R. Pereira, and Ângelo Carneiro

Introduction: Cerebral air embolism is a rare neurologic complication that can occur in the setting of several medical procedures, with air entering vascular structures. Proposed mechanisms for cerebral lesions induced by air embolism are: ischemic, due to interruption of cerebral arterial flow, or inflammatory, because air microbubbles impair the vascular endothelium, causing a breakdown of the blood–brain barrier (BBB), activation of immune cells and inflammatory proteins and platelet and leucocyte adhesion.
Case Presentation: A transthoracic CT-guided lung biopsy was performed in a 75-year-old woman. After the procedure the patient presented sudden loss of consciousness followed by quick recovery and focal neurologic deficits (left neglet and hemiparesis), NIHSS 10. CT, CTA and CT-perfusion showed no remarkable changes besides minimal amount of air in the cavernous sinus. The patient performed one session of hyperbaric oxygen therapy (HBO) that started 4 hours after symptoms onset. The following days showed progressive recovery and one week later had no neurological deficits. MR two days after event showed right cortico-subcortical fronto-parietal foci of hyperintensity on T2 weighted sequences and in the deeper white matter of centrum semiovale; no diffusion restriction and elevation of centrum semiovale signal on ADC.
Conclusions: Hyperbaric oxygen therapy is associated with improved cerebral oxygenation, reduced (BBB) breakdown, decreased inflammation, reduced cerebral oedema, reduced metabolic derangement and decreased apoptotic cell death. This patient had no restricted diffusion in the acute phase, suggesting beneficial effects of HBO in reducing cytotoxic oedema and possible secondary brain infarction.

From the Lisbon Stroke Summit, Lisbon, Portugal. 6–7 April 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 1):P24

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