IJCNMH ARCpublishing
ADVANCED SEARCH


Current issue

Debate


Is IV rtPA in patients with LVO still beneficial? - read full article

By: Yvo Roos

Several trials have shown that endovascular treatment (EVT) following intravenous alteplase (IVT) improves outcome of patients with acute ischemic stroke and a proximal intracranial occlusion. A meta-analysis of five randomized trials (Hermes collaboration, Lancet 2016), which also included patients with contraindications for IVT, showed that the effect of EVT on outcome is not influenced by IVT. The question arises whether IVT is of additional benefit to patients eligible for EVT. Some authors point out possible side-effects of IVT pretreatment. Especially the effect of IVT pretreatment to delay and increase hemorrhagic complications is often described as a potential problem. Others, direct attention to the potential benefit of IVT pretreatment to facilitate mechanical removal of thrombi and the dissolution of distal emboli which might develop during EVT. Reviews on observational studies on the subject present contradictory results, probably because of the many confounders in these observational studies. Like confounding by indication as direct mechanical thrombectomy patients are mostly treated outside the 4,5 hour time window from onset, while patients treated with IVT pre-treatment are always treated within 4,5 hour. Results of randomized clinical trials (RCT’s) are therefore needed. Currently, several RCT’s are investigating EVT with or without IVT. The ongoing MR CLEAN-NoIV: Multicenter Randomized Clinical trial of Endovascular Treatment for Acute ischemic stroke in the Netherlands NO IV trials, the SWIFT DIRECT: Solitaire With the Intention For Thrombectomy Plus Intravenous t-PA Versus DIRECT Solitaire Stent-retriever Thrombectomy in Acute Anterior Circulation Stroke, the DIRECT-MT: Direct Intra-arterial Thrombectomy in Order to Revascularize AIS patients with Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals and the DIRECT-SAFE: A Randomized Controlled Trial of DIRECT Endovascular Clot Retrieval Versus Standard Bridging Thrombolysis With Endovascular Clot Retrieval will provide definitive answers on the potential additional clinical benefit of IVT pretreatment in LVO patients receiving EVT. Results of the DIRECT-MT are expected at the beginning of 2020, later that year followed by results of the MR CLEAN-NoIV study.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):D1

Icon_pdf Download PDF

Debate


TNK has come to stay - read full article

By: Juan F. Arenillas

Recombinant tissue plasminogen activator (rt-PA) is the approved thrombolytic drug to treat acute ischemic stroke patients with significant disability within the first 4.5 hours after symptom onset. This drug has well known efficacy and safety limitations, such as low recanalization rate in large-artery occlusions and risk for hemorrhagic transformation, that have encouraged the development of new reperfusion therapies for stroke, including newer thrombolytic drugs. Another disadvantage is the need for i.v. perfusion during one hour, which leads to technical requirements. Tenecteplase (TNK) is a genetically modified variant of rt-PA with a higher specificity for fibrin and a longer half-life, which allows for a single bolus administration. It was chosen as the preferable thrombolytic drug for ST elevation myocardial infarction due to a lower rate of systemic hemorrhagic complications as compared with rt-PA. There is a growing body of evidence supporting a transition from rt-PA towards TNK also for acute cerebral ischemia. A randomized clinical trial conducted in ischemic stroke patients with acute large artery occlusion and evidence of salvageable tissue on CT perfusion, showed superiority of TNK over rt-PA in efficacy and safety. Other clinical trials were based on plain CT and showed comparable efficacy and safety of rt-PA vs. TNK. Recently, the EXTEND-ia-TNK clinical trial has shown that TNK before endovascular therapy is associated with a higher incidence of reperfusion and better functional outcome as compared with rt-PA. After this evidence, in our center we have amended our protocol to start using TNK before thrombectomy when bridging therapy is indicated, while we wait for the results of EXTEND-TNK with a larger sample. Futile transfers for thrombectomy are a clinical and organizational problem. The easiness and rapidness of administration, together with a higher efficacy in the setting of large-artery occlusions amenable for endovascular therapy, make it a very attractive thrombolytic drug in the setting of drip-and-ship patients for endovascular therapy. Regarding the time window for administration, giving its favorable safety profile, RCTs such as TEMPO-2 are under conduct to test whether TNK could also be given within the first 12 hours in high-risk minor stroke patients. Transition from rt-PA towards TNK in acute ischemic stroke is already happening. Finally, economical arguments also favor TNK.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):D2

Icon_pdf Download PDF

Debate


Should EVT for LVO be offered to children? - read full article

By: Maja Steinlin

There are many reasons, why EVT should not be offered to children with LVO. The first and most prominent: Good effect of EVT is proven in adult but not in children. The only paediatric study on recanalization, the TIPS study, had to close due to failing in recruitment. Of the 95 children screened, non fulfilled the inclusion criteria. 54% had a mimic of stroke. Mimics in paediatric stroke are a big problem: in acute focal deficit, only 7% of children (adults 74%) suffer stroke! 23% of children screened had contraindications, mostly due to underlying aetiology. Childhood stroke is a multiple risk problem – many of them a contraindication for EVT. More than 50% of children with stroke have an underlying arteriopathy – but many of them due to an inflammatory process, thus being at high risk for EVT. One third have a cardiac origin. However, delay of diagnosis in this group might put them out of the treatment window. In general, the problem of delayed diagnosis did improve over the last two decades but is a persistent concern. Knowledge on EVT in children is scarce: Lately, two series of children after recanalization treatments have been published. In the French series 11/13 children had iv thrombolysis. The Swiss cohort included 11/16 after interventional recanalization. Both study show feasibility without significant risk. The Swiss study did show no better outcome in children treated by recanalization, the only predictor for outcome was pedNIH at diagnosis. Finally yet importantly, intracranial vessels of children are still small: carotid and medial cerebral arteries reach adult size at 6 and 5 years respectively– thus a technical challenge! In summary, missing indication (mimics), increased or unknown risk (different risk profile), missing technical experience in preschool children and the complete lack of data supporting EVT should restrain us from offering this aggressive treatment.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):D3

Icon_pdf Download PDF

Debate


Is there a role for reversal agents in anticoagulant associated ICH? - read full article

By: João Sargento Freitas

Intracerebral hemorrhage (ICH) is a potentially devastating medical condition and its treatment recommendations are not always consensual between scientific organizations and physicians. This is particularly the case in ICH of patients taking anticoagulants. The first controversy is immediately in its definition. What is “anticoagulant associated ICH”? Is there really such a condition in humans? Is there any pathological distinction from other ICH or is anticoagulant use and ICH just two conditions that may coexist and potentiate each other? It should be noted that it is widely recognized by observational studies that impaired haemostasis is a predictor of worse outcome after ICH. However, to date, no randomized study has demonstrated an improvement in clinical outcome by using reversal agents in this setting. Therefore, treating guidelines either state that no formal recommendations can be made or provide suggestions of approaches with weak evidence. During this session the existing data to support pathological backgrounds and treatment options will be critically reviewed, aiming to promote the discussion on this important topic of everyday clinical care.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):D4

Icon_pdf Download PDF

Debate


Carotid artery plaque: how essential is imaging? - read full article

By: J. David Spence

Measurement of carotid plaque burden and assessment of carotid plaque characteristics are very important in predicting risk of stroke/myocardial infarction/vascular death, and in management of atherosclerosis. By quartile of total carotid plaque area (TPA), the 5-year risk of these events is approximately 5%, 10%, 15% and 20%, after adjustment for a broad panel of risk factors. “Treating arteries instead of treating risk factors” markedly reduces risk. Among patients with asymptomatic carotid stenosis, this approach reduced the 2-year risk of stroke and myocardial infarction by more than 80%. Trying to treat arteries without measuring plaque burden would be like trying to treat hypertension without measuring blood pressure.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):D5

Icon_pdf Download PDF

Debate


The Future of Stroke Imaging: What to Expect? - read full article

By: Donald Frei

Imaging evaluation of the ischemic stroke patient who is a potential candidate for intervention is simple. 1. Select patients who would benefit from treatment. 2. Exclude patients who wouldn't benefit, either because treatment is futile because their stroke is complete or there is a high risk of developing symptomatic hemorrhage. For the patient who is a potential candidate for IV treatment, the standard exclusion criteria is hemorrhage or completed stroke in > 1/3 of the MCA territory as seen on a head CT. The primary aim of imaging in this circumstance is to decrease the risk of symptomatic intracranial hemorrhage. More recent trials looking at new IV therapies and expanding the treatment window are using more sophisticated imaging techniques to more accurately identify core infarct and ischemic penumbra. For the patient who is a potential candidate for thrombectomy, all of the positive thrombectomy trials published in 2015 utilized vascular imaging (CTA) to identify large vessel occlusion (LVO). There was variability in identification of salvageable brain/ischemic penumbra. This ranged from the simplicity of an ASPECTS score to the complexity of collateral score, core infarct volume and quantification of the ischemic penumbra. There are options for the type of imaging used to screen the ischemic stroke patient. Both CT and MRI can identify LVO quite well. They both can identify core infract size. MRI is more sensitive than CT for identifying core infarct, but can take more time. There are options for identification of the ischemic penumbra. The quality of collateral circulation determines the rapidity of core infarct growth. Mismatch algorithms are available by all CT and MR manufacturers and there are now automated agnostic systems that can give us this data. There are no developments in AI to detect LVO. What imaging is just enough to give us the go ahead to treat? How much it too much? So many options, so little time.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):D6

Icon_pdf Download PDF

Debate


Can we prevent futile recanalization in patients undergoing endovascular treatment for acute ischemic stroke? - read full article

By: P. Vanacker and H. Janssen

Endovascular stroke treatment is highly effective and shows low risk of complications. Futile recanalization, defined as lack of clinical benefit despite angiographic recanalization, is an important limitation of this treatment modality for acute ischemic stroke. Its prevalence is highly variable and up to 47% in the IMS III clinical trial. From a pathophysiological point of view, a multitude of mechanisms cause this failure, mainly a combination of clot composition, clot burden, bad collateral circulation, subacute re-occlusion, large hypoperfusion volumes, microvascular compromise and impaired cerebral autoregulation. The financial impact on health care resources could be huge if we could predict and impact futile recanalization rates. However, refusing endovascular treatment remains multi-parametric decision taking into account various clinical and imaging finding. Defining futile recanalization should be very reliable. The predictors for futile recanalization can be divided in preprocedural, procedural and post-EVT parameters. Various single parameters have been advocated and are clinically used to withhold endovascular therapy such as older age, female gender, high NIHSS, large infarct volumes, late time window, etc. Imaging-based selection should incorporate the analysis of the presence of large DWI infarct lesions in deep white matter, moderate to severe leukoaraiosis and poor collaterals, as they predict poor prognosis despite successful recanalization. Robust collaterals warrant consideration for recanalization therapy promoting the chance of better prognosis. Above four stent retriever passes, the functional outcomes seems not more favorable than without recanalization (OR 1.70; 95% CI 0.42-6.90). Further, recanalization has been associated with reduced ischemic brain edema in patients with good clinical outcome. The edema volume are significantly higher in patients with a mRS 5-6 (8,6ml; (2.0–49.8 ml) vs. mRS 0-4 (1.6ml; 0.2-4.2ml). An important subgroup of patients are the very elderly. A substantial proportion of nonagenarians shows futile recanalization. Clinical response, measured by delta mRS, was better in the group with successful compared to unsuccessful recanalization [2.8±1.6 vs. 3.9±1.2 (mean±SD)]. Nonetheless, meaningful recanalization was low (18.2%), especially with respect to 75% of patients having a pre-stroke mRS?2. Treatment decisions should be made on case-by-case evaluation, keeping in mind limited chances of favorable outcome and high risk of mortality.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):D7

Icon_pdf Download PDF

Debate


Can we prevent futile recanalization? - read full article

By: Pasquale Mordasini

Mechanical recanalization of acute ischemic stroke due to large vessel occlusion (LVO) of the anterior circulation has been shown in several randomized controlled trials to be a highly effective treatment with high recanalization and low complications rates and consecutively a low number of patients needed-to-treat (NNT) in order to achieve favorable clinical outcome. However, despite successful recanalization, not all patients achieve favorable clinical outcome (usually defined as a mRS of 0-2 or clinical improvement), which is called “futile recanalization”. Major predictors of clinical outcome include stroke severity (clinical scores, NIHSS), patient age, size and location of infarction on imaging, time window, ischemic stroke mechanism, comorbid conditions, complications of stroke, recanalization success and treatment-related complications. These parameters have shown to be of value to predict the chance of achieving a favorable outcome. However, more and more studies show that endovascular thrombectomy is of benefit to most patients with acute ischemic stroke caused by LVO of the anterior circulation, irrespective of patient characteristics. Up to now, it is not possible to reliably predict “futile recanalization” in an individual patient either by clinical or imaging parameters or a combination of both. Even if patients with LVO may show a low potential of achieving favorable outcome, they should not be considered as candidates for “futile recanalization” per se. Refusing treatment because of potential “futile recanalization” is a “once in a life-time decision” for individual patients denying them the chance of a potential benefit of therapy. Therefore, refusing treatment in LVO stroke of the anterior circulation remains a multi-parametric decision taking into account several clinical and imaging parameters, but nevertheless, if in doubt – treat!

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):D8

Icon_pdf Download PDF

Oral Presentation


The “Too Late, Too Good and Too Distal to Treat” Dilemma - read full article

By: João Pedro Marto and Patrik Michel

Introduction: Intracranial aneurysms are found in 3.7% patients with acute ischemic stroke. Although intravenous alteplase (IV tPA) poses no additional risk of rupture in these patients, there might be implications regarding endovascular mechanical thrombectomy.
Case Report: We report a case of an 81-year-old woman who presented at the emergency department with a sudden onset of vertigo, nausea and vomiting, right gaze palsy, right homonymous hemianopsia, left hemiparesis, right ataxia and dysarthria. AngioCT revealed occlusion of both intracranial vertebral arteries and basilar artery. IV tPA was administered and the patient was admitted for endovascular thrombectomy. Aspiration mechanical thrombectomy of the right vertebral artery was performed. However, there was a severe proximal basilar artery stenosis due to an atherosclerotic plaque. Balloon angioplasty and stenting of the basilar artery was performed. Following recanalization, an unruptured basilar tip aneurysm was incidentally detected. Considering the need for double antiplatelet therapy on a patient already under IV tPA, endovascular coiling was decided, with occlusion of the aneurysm. The patient had a good clinical evolution being discharged with left facial palsy and mild left ataxia. 
Discussion: Few authors have addressed the management of coincidental aneurysms of the target vessel during a mechanical thrombectomy procedure. Aspiration techniques that do not pass the thrombus and navigate into invisible vessel segments might have lower risk of rupture compared to stent retrievers. However, reperfusion of the occluded vessel could result in an abrupt increase in hemodynamic stress inside the aneurysm. This case illustrates the need of a complete training in neurointervention. 

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):O1

Icon_pdf Download PDF

Oral Presentation


Thrombectomy—behind the curtain - read full article

By: Bruno Cunha, Diana Melancia, Teresa Morais, Isabel Fragata, Patrícia Ferreira, and João Reis

Introduction: Intracranial aneurysms are found in 3.7% patients with acute ischemic stroke. Although intravenous alteplase (IV tPA) poses no additional risk of rupture in these patients, there might be implications regarding endovascular mechanical thrombectomy. 
Case Report: We report a case of an 81-year-old woman who presented at the emergency department with a sudden onset of vertigo, nausea and vomiting, right gaze palsy, right homonymous hemianopsia, left hemiparesis, right ataxia and dysarthria. AngioCT revealed occlusion of both intracranial vertebral arteries and basilar artery. IV tPA was administered and the patient was admitted for endovascular thrombectomy. Aspiration mechanical thrombectomy of the right vertebral artery was performed. However, there was a severe proximal basilar artery stenosis due to an atherosclerotic plaque. Balloon angioplasty and stenting of the basilar artery was performed. Following recanalization, an unruptured basilar tip aneurysm was incidentally detected. Considering the need for double antiplatelet therapy on a patient already under IV tPA, endovascular coiling was decided, with occlusion of the aneurysm. The patient had a good clinical evolution being discharged with left facial palsy and mild left ataxia. 
Discussion: Few authors have addressed the management of coincidental aneurysms of the target vessel during a mechanical thrombectomy procedure. Aspiration techniques that do not pass the thrombus and navigate into invisible vessel segments might have lower risk of rupture compared to stent retrievers. However, reperfusion of the occluded vessel could result in an abrupt increase in hemodynamic stress inside the aneurysm. This case illustrates the need of a complete training in neurointervention.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):O2

Icon_pdf Download PDF

Oral Presentation


Is endovascular treatment the best choice for distal artery occlusions? - read full article

By: Joana Osório, Bruno Cunha, Isabel Fragata, Patrícia Ferreira, Ana Paiva Nunes, and João Reis

Background: Due to the eloquence of its specific branches, distal artery occlusions may lead to dramatic clinical presentations with a huge rate of disability. Endovascular treatment (EVT) for small vessel like M3 branch is still controversial regarding efficacy and safety. Indication for EVT in these cases is still unclear since there are limiting data either for primary and rescue distal occlusions. 
Case report: We report a case of a 69-year-old woman with history of hypertension, non-specified arrhythmia and dyslipidaemia, who presented at the ER with dysarthria, right oculocephalic deviation, left central facial palsy and left hemiparesis, scoring 21 points in NIHSS. The initial computed tomography (CT) showed no signs of acute lesion (ASPECTS 10) and the CT-angiography showed a right middle cerebral artery occlusion (distal branches, M2-M3 segments), with a good collateral circulation. Intravenous t-PA was administered, and she arrived in the angiography room 3h20m after the symptoms onset, scoring 12 points in NIHSS. Angiography showed an occlusion of the right M3 segment (parietal branch, superior division) and endovascular clot aspiration was performed with the 3MAX system, with only one pass. A TICI 2b was obtained in the end of the procedure, with no complications and about 4h after the symptoms onset. The 24h-control CT showed a hypodense lesion in the right parieto-temporal and insular regions. The patient was transferred to the resident hospital 2 days after the intervention, with a slight left hemiparesis and hemihypoesthesia, scoring 4 points in NIHSS and a mRS of 2. 
Conclusions: EVT is useful for acute distal occlusions and prompt recanalization results in a good clinical outcome. Data suggest that patients with isolated M3 occlusions show similar severity of disease, recanalization rates and clinical outcome as patients with proximal occlusions. Indeed, success rates of EVT in distal arteries might be higher, since distal occlusion is a more localized condition, and its risk for parenchymal hemorrhage seems to be smaller.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):O3

Icon_pdf Download PDF

Oral Presentation


Repeated large vessel occlusion in a young adult - read full article

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

Background: Ischemic stroke in young adults is reported as uncommon, comprising less than 10% of all stroke patients. Therefore, these patients constitute a diagnostic challenge, many of them with no risk factors for atherosclerosis and no clear etiological diagnosis even after a thorough investigation. 
Methods: We describe a case of a young female who was submitted to multiple endovascular treatments, with recurrent right middle cerebral artery (MCA) occlusion. The aetiology is not yet totally clarified. 
Results: We report a case of a 42-year-old woman, with personal history of migraine, on oral contraceptives. She was admitted at our hospital 45 minutes after a sudden onset of anosognosia, right oculocephalic deviation, left hemianopia, left central facial palsy, dysarthria and left hemiparesis and hemihypoesthesia, scoring 13 points on the NIHSS. Computed tomography (CT) showed no signs of acute vascular lesion and CT-angiography revealed right MCA occlusion, at the M1 segment. IV thrombolysis with rt-PA was started, and the patient was taken to the angiography suite. Occlusion of the proximal right M1 segment was confirmed, as well as a small ulceration with a non-occlusive thrombus in the right internal carotid bulb. A favourable recanalization was achieved using aspiration. After the procedure, clinical improvement was noticed, but minutes later, a new onset of the previous deficits occurred. Transcranial Doppler (TCD) study showed a re-occlusion of the right M1 segment. Immediately, a new thrombectomy procedure was performed, again with favourable recanalization - TICI 2C. Microembolic signals were observed during the transcranial doppler monitoring (TCDM), and considering the internal carotid wall changes, IV eptifibatide was started. Follow-up MRI at 24 hours showed multiple acute ischemic lesions in the right MCA territory. On the third day of hospitalization the patient presented with the previously described deficits, and again, TCDM showed a right M1 occlusion. A new angiography was performed, showing a focal stenosis of M1. IA vasodilators were administered with resolution of the stenosis. A complete etiological study was carried out, yielding a small patent foramen ovale. The main diagnostic hypotheses of carotid disease or intracranial dissection were excluded. The patient was discharged with aspirin 100mg/daily. Final NIHSS at discharge was 3, and mRS at 3 months was 2. 
Conclusion: Although ischemic stroke is a widely studied pathology, sometimes there are clinical cases difficult to approach and treat. Large vessel reocclusion should not be contraindicated for a new endovascular approach, and may favourably modify the prognosis.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):O4

Icon_pdf Download PDF

Oral Presentation


Acute phase treatment in central retinal artery occlusion: hyperbaric oxygen therapy, thrombolysis or even both? - read full article

By: Daniel Ferreira, Carolina Soares, João Tavares-Ferreira, Tiago Fernandes, Rui Araújo, and Pedro Castro

Background: Central retinal artery occlusion (CRAO) is a neuro-ophthalmological emergency. Evidence shows a finite time window for acute interventions aimed at retinal sparing. No guideline-endorsed evidence for acute treatment is available with current options including revascularization (e.g. intravenous thrombolysis - IVT) and retinal oxygenation (e.g. hyperbaric oxygen therapy - HBOT) therapies. 
Objective: We report a 3-case series of patients with a CRAO who underwent acute phase treatment with either HBOT, IVT or combined IVT and HBOT. 
Clinical cases: Case 1: A 35-year-old female presented with an acute visual loss in her right eye (OD). Fluorescein angiography (FA) and optical coherence tomography (OCT) revealed CRAO. She was submitted to 3 sessions of HBOT (100% O2 at 2.4 atmosphere absolute-ATA), discontinued after a barotrauma of the middle ear. Visual defects on the nasal field were kept afterwards but visual acuity (VA) improved from counting fingers to 1.0 in the remaining fields. Case 2: A 65-year-old male presented with CRAO in his left eye (OS), with 3 hours of evolution. He underwent IVT with tPA (0.9mg/kg). Orbital sonography, FA and OCT confirmed the presence of an embolus and retinal ischemia. VA improved from light perception to 0.1. Case 3: A 21-year-old male showed acute visual loss in his OD with 3 hours of evolution. OCT and retinography identified CRAO. The patient was submitted to IVT (tPA-0.9mg/kg) followed by 12 sessions of HBOT (2.4 ATA). After 6 days, VA improved from hand motion to 0.4. 
Conclusion: Our case series illustrates the different options and possible outcomes in acute management of a rare, but highly morbid, cerebrovascular disorder. Future clinical trials are warranted to tackle current difficulties in CRAO treatment.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):O5

Icon_pdf Download PDF

Oral Presentation


Vertebral dissection with distal occlusion – where to start? - read full article

By: Sofia Almeida Xavier, Miguel Quintas Neves, Ana Rita Silva, Inês Carvalho, Jaime Rocha, and José Manuel Amorim

Vertebral artery (VA) dissection is a rare but relevant cause of stroke especially in young patients. Treatment strategy depends on several factors such as timing, location and extent of the disease. A 61-year-old man presented with a 2-hour history of non-fluent aphasia. The patient was somnolent, and the exam revealed naming impairment, left ptosis, slight abduction of the left eye, right central facial paralysis and right arm paresis. Cranial CT showed no signs of acute ischemia. CT angiography revealed a right VA proximal stenosis, a V2 segment filling defect and distal occlusion of the top of the Basilar Artery (BA) extending to the left Posterior Cerebral Artery. Mechanical thrombectomy (MT) was attempted by the left VA. After 2 passes, control angiogram revealed extended occlusion to the proximal BA. The right VA was then catheterized, distal MT was performed, and a stent was deployed on the right V1 segment. Control angiogram showed patency of the stent but persistent occlusion of the top of the BA. As a microcatheter could not progress through the stent, MT was then again performed by the left VA. After the procedure MRI excluded acute ischemic lesions of the brainstem or thalamus. The patient recovered most of the deficits and was kept on dual antiplatelet therapy. VA dissections with distal occlusion are challenging cases. Stenting in the acute phase is controversial as most dissections heal spontaneously and thrombus formation can be prevented with antiplatelets. This case stresses the importance of evaluating the diseased VA before delineating your strategy and also the necessity to recanalize highly thrombogenic dissections in the acute setting.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):O6

Icon_pdf Download PDF

Oral Presentation


Acute ischemic stroke due to isolated intracranial dissection with aneurysmal dilatation: Does everyone know what to do? - read full article

By: João Pedro Marto and Patrik Michel

Background: An isolated intracranial dissection is rare cause of stroke and presents as a therapeutic dilemma in the acute setting. The association with an aneurysmal dilatation increases the risk of bleeding, making the decision to perform any acute treatment even more challenging. Currently there are no consensus on how to treat these patients. 
Clinical case: A 37-year-old woman, active smoker and with history of migraine without aura, was admitted in the emergency department 45 minutes after the onset of a sudden left hemiparesis. Presence of facial asymmetry and occipital headache in the previous week were latter reported. At examination the patient presented a left hemiparesis with ipsilateral sensory impairment and dysarthria (NIHSS 9). MRI showed an acute and subacute right lenticulostriate ischemic infarct and a right MCA dissection with a partially thrombosed aneurysmal dilatation. There was no MCA occlusion and the pseudoaneurysm wall showed contrast enhancement in T1-weighted images. MR perfusion imaging revealed a hypoperfusion in the right MCA territory. Due to an established subacute infarct and an aneurysmal dilatation with high-risk of rupture, intravenous thrombolysis was withheld. After multidisciplinary discussion, the patient was treated with endovascular coiling and permanent stenting, without immediate complications. At 3-months, the modified Rankin Score was 2, but after the onset of temporal headaches, imaging disclosed a pseudoaneurysm growth, and a new endovascular treatment was performed. 
Conclusion: While some experts’ opinion proposes that intravenous thrombolysis should not be withheld in ischemic stroke due to intracranial dissection, the presence of concomitant aneurysmal dilatation raises additional safety concerns. Due to the high-risk of rupture, dissecting aneurysms may benefit from early endovascular treatment.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):O7

Icon_pdf Download PDF

Oral Presentation


Better late than never—vertebral artery stenting and thrombectomy after 3 days - read full article

By: Hugo Mota Dória, Catarina Mendes Pinto, Ricardo Martins, Gonçalo Videira, Viriato Alves, and Ângelo Carneiro

Introduction: Besides being associated with higher mortality, posterior circulation occlusions are less predictable when compared to anterior ones. The optimal therapeutic approach is not as well-known and many aspects are still a matter of debate, including the appropriate time window for thrombectomy. 
Case report: A 55-year-old female with a modified Rankin Scale (mRS) of 0 had a past medical history that was remarkable for breast cancer, having been treated with chemo/radiotherapy and discharged from follow-up three years prior. She had an episode of loss of consciousness that lasted less than one minute, with no prodromes or involuntary movements. She then developed an intense right-sided headache, photo and phonophobia, which lead her to a peripheral hospital. Her neurological examination was unremarkable (NIHSS=0). Considering she had no history of migraine, a CT scan was performed which revealed a left thalamic infarct and prompted a CT angiogram. CTA revealed a severe stenosis of the left vertebral artery at the level of its origin, as well as a basilar tip occlusion. Given that headache was her only symptom, she was kept under a watchful waiting policy and was started on antiplatelet therapy. Three days later there was neurological worsening with somnolence, limitation of upward gaze, left internuclear ophthalmoplegia (IOP), dysarthria, right hemiparesis and left appendicular ataxia (NIHSS=10). A second CT revealed new infarcts on the left cerebellar hemisphere and thalamo-mesencephalic junction. The patient was transferred to a thrombectomy center where CT perfusion revealed areas of mismatch on the left cerebellar hemisphere and occipital lobe. The findings on CTA were the same as described before. The right vertebral artery ended in posterior inferior cerebellar artery so the left one was the only access to the basilar occlusion. The severe stenosis was treated with a drug-eluting stent, allowing for distal catheterization, and then thrombectomy was performed. Control CT scan 24 hours later revealed small petechial haemorrhages, with no new ischemic lesions. The patient was left with a residual left IOP, mild left ataxia and no motor deficit; her mRS at 3 months was 1. 
Conclusion: We present the case of a tandem basilar tip occlusion submitted to vertebral artery stenting and thrombectomy 3 days after its initial presentation with a favourable outcome. 

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):O8

Icon_pdf Download PDF

Poster


Seeing beyond the eyes: successful treatment of basilar artery occlusion - read full article

By: Anna Viola Taulaigo, Marisa Mariano, Patrícia Ferreira, Jaime Pamplona, João Reis, and Ana Paiva Nunes

Background: Posterior circulation (PC) strokes often present with non-specific symptoms, delaying diagnosis and treatment. Moreover, considering events with low National Institutes of Health Stroke Scale Scores (NIHSS) at presentation, PC strokes have worse outcome than anterior circulation (AC) strokes. Acute phase treatment of minor PC strokes is not standardized and carefully clinical evaluation is warranted. 
Clinical case: We report the case of a 78-years-old woman who presented to the emergency department with new onset anisocoria and flattened left nasolabial fold. Two hours before admission, she reported transient left sided paraesthesias and left arm weakness. Past medical history was relevant for hypertension, dyslipidaemia and unspecified arrhythmia, without anticoagulation therapy. Brain computed tomography (CT) showed basilar artery (BA) hyperdensity with no ischemic or haemorrhagic lesions and CT angiography confirmed top of BA occlusion. Despite minor neurological deficits (NIHSS 1), she started fibrinolytic therapy with recombinant tissue plasminogen activator (rt-PA) (0.9 mg/kg). She underwent cerebral angiography which showed recanalization of BA and occlusion of the P2 segment of left posterior cerebral artery (PCA). While attempting thrombectomy, spontaneous recanalization of P2 segment occurred with occlusion limited to P3/P4 segment and partial thrombus aspiration was performed. Magnetic resonance evaluation showed minimal acute ischemic infarctions in right superior cerebellum, temporal and occipital parasagittal left cortex, suggesting embolic origin. Etiologic study revealed atrial fibrillation and she started anticoagulation therapy. She was dismissed completely asymptomatic and with no functional impairment. 
Conclusion: This case showed an example of major vessel occlusion with clinical minor neurological deficit, in which timely and successful treatment was performed, to prevent more severe consequences of PC stroke.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P1

Icon_pdf Download PDF

Poster


Double occlusion, double thrombectomy - read full article

By: Bruno Cunha, Danila Kuroedov, Isabel Fragata, Ana Paiva Nunes, and João Reis

Introduction: The prevalence of acute bilateral middle cerebral artery (MCA) occlusion has not been precisely studied, with only a few cases reported in the literature. Patients present with bilateral neurological deficits and coma, mimicking a basilar artery stroke. 
Case Report: We report a case of an 85-year-old woman presenting with a sudden right hemiparesis and dysarthria rapidly followed by neurological deterioration and coma with a Glasgow Coma Scale (GCS) of 6. Neuroimaging revealed a left insular gray-white matter de-differentiation and occlusion of both MCAs at their proximal segment (M1). Intravenous alteplase was administered and the patient was admitted for endovascular thrombectomy. Direct aspiration first pass technique thrombectomy was performed on both MCAs with complete recanalization after one pass on each artery. Follow-up brain magnetic resonance imaging (MRI) documented bilateral acute phase infarcts of the corpus striatum and insulae. At day 27 the patient was transferred to a rehabilitation unit with a GCS of 8 and tetraparesis (modified Rankin Scale of 5). At 3 months she was discharged to a continuous care unit with significant improvement of her conscious state (GCS of 14) and slight improvement of her tetraparesis (modified Rankin Scale of 4). 
Discussion: Acute bilateral occlusion of both MCAs is usually associated with poor prognosis with anecdotal reports of good functional outcome after revascularization by stent retriever thrombectomy. In our case, aspiration thrombectomy achieved an early and complete revascularization. Despite establishment of bilateral cerebral infarction and residual tetraparesis, a significant neurological improvement was achieved in this very severe stroke.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P2

Icon_pdf Download PDF

Poster


Treatment beyond guidelines - read full article

By: Danila Kuroedov, Joana Osório, Patrícia Ferreira, Ana Paiva Nunes, and João Reis

Introduction: The assessment of ischemic stroke lesions on computed tomography (CT) using ASPECTS is widely used to manage acute stroke treatment. Current guidelines state that endovascular treatment is indicated if ASPECTS is 6 or better. However, some patients with relatively poor ASPECTS may still have a reasonable chance of recovery. 
Case Report: We report a case of a 50-year-old woman who presented in the ER Department with sudden altered mental status and left hemiparesis, with unknown onset of symptoms. CT scan revealed extensive infarction of the MCA vascular territory, ASPECTS 0, and CTA showed occlusion of the M1 segment. MRI showed a slight mismatch between diffusion/FLAIR, and after discussion with the neurointerventional team, EVT was performed, obtaining a TICI 3 recanalization rate. Soon after patient´s admission to the Stroke unit her mental status worsened, with CT showing petechial haemorrhages affecting basal ganglia and oedema with severe parenchymal mass effect. We initiated mannitol perfusion, with no response, with the patient scoring a GCS 8 at that point, being therefore submitted to decompressive craniectomy. The patient was then re-admitted to the stroke unit and then transferred to an Internal Medicine unit where she had a positive recovery – scoring GCS 15, NIHSS 13 and mRS 4 at discharge. 
Conclusion: It’s clear that overviewing all key informations like patient age, baseline functional status, comorbidities, location of occlusion, MRI FLAIR/diffusion or perfusion mismatch, and patient preference, must be regarded in decision making for recanalization therapies. When considered in this context, poor ASPECTS does not necessarily mean that there will not be room for endovascular treatment.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P3

Icon_pdf Download PDF

Poster


Acute occlusion with subacute contralateral lesion—a dilemma? Maybe not - read full article

By: Maria Amaral, Carolina Pinheiro, Cristina Sousa, Patrícia Ferreira, and Ana Paiva Nunes

Endovascular thrombectomy is an effective procedure for the treatment of acute ischemic stroke caused by occlusion of a major vessel. However, it’s safety in patients with subacute lesions in other locations is not established. We present a case of a 79-year-old woman, admitted to the emergency room for prostration and altered speech 6 hours after symptom onset. She was drowsy but arousable to command, global aphasia, right homonymous hemianopsia, right central facial palsy, right hemiparesis with muscle strength grade 1, and right hypoesthesia, accounting for an NIH Stroke Scale (NIHSS) 22. Brain CT-scan showed an ASPECTS score 7 on the left hemisphere and distal M1 occlusion of the left middle cerebral artery. Simultaneously a subacute ischemic lesion with petechial haemorrhage component was identified on the right ACM territory. As intravenous thrombolysis was contraindicated, endovascular thrombectomy was performed, with a TICI 2b recanalization. She was admitted in the Stroke Unit where atrial fibrillation was documented. The 24h follow-up CT-scan revealed a left temporal ischemic lesion with a petechial haemorrhagic component. She started acetylsalicylic acid and prophylactic enoxaparin. At the 6th day of admission, there was an aggravation of the neurological status with an enlargement of the left haemorrhagic component and antiplatelet therapy was stopped. At the 10th day, after clinical and imagiological improvement, acetylsalicylic acid was restarted and at the 28th day she was discharged from the hospital with the diagnosis of acute ischemic stroke of cardioembolic origin, with a NIHSS 7 and mRs score 2. The treatment for patients with acute ischemic stroke and contraindication for intravenous thrombolysis is not established however endovascular thrombectomy seems to be a good alternative with favourable outcomes.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P4

Icon_pdf Download PDF

Poster


Atrial fibrillation, acute stroke and cerebral arteriovenous malformation: best approach? - read full article

By: Gonçalo Cabral, Filipa Serrazina, Ana Luís, Sofia Calado, and Miguel Viana Baptista

Atrial fibrillation (AF) is the most common risk factor for cardioembolic stroke. The mainstay of preventive therapy for this stroke is anticoagulation. However, a substantial number of patients may present comorbidities, such as cerebral arteriovenous malformations (AVM), which may limit the use of anticoagulants due to the high haemorrhagic risk. We report a 72-year-old woman, with previous background of hypertension and non-valvular AF treated with rivaroxaban. In 2017, after an acute neurological dysfunction episode (aphasia), a temporal hematoma due to a cerebral AVM (Martin-Spetzler grade 2) was diagnosed. The anticoagulation was suspended at that time. One year later, she was admitted for ictal left motor deficit and imbalance of gait noticed 3 days earlier. She had slight language deficit, mild left hemiparesis with left central facial paresis and mild dysarthria (NIHSS 5). The MRI showed an acute right pontine stroke. The case was discussed in multidisciplinary team [high embolic risk (CHA2DS2-VASc score =5), haemorrhagic risk due the AVM and HAS-BLED = 3] and it was decided first to proceed with the resection of the brain AVM. Four weeks after surgery oral anticoagulation with Dabigatran Etexilate 150mg bid was started. Three months later, the patient maintained only a mild language deficit (NIHSS 1, mRs = 1). The present case illustrates the complexity of management patients with high embolic and simultaneously haemorrhagic risk. Further studies are necessary to evaluate the effect of the new oral anticoagulants on the risk of further intracranial hemorrhage after cerebral AVM treatment.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P5

Icon_pdf Download PDF

Poster


Cerebral sinus venous thrombosis in a patient with complete gonadal dysgenesis - read full article

By: Federica Parlato, Pedro Gaspar, Diana Aguiar de Sousa, and Sandra Braz

Cerebral sinus venous thrombosis (CSVT) is a rare form of venous thrombosis (VTE), but nevertheless one important cause of stroke in young women. Complete gonadal dysgenesia (CGD) is a rare congenital disorder of sex development characterized by normal female genitalia and fibrotic non-productive gonads in which hormone replacement therapy (HRT) is crucial to induce secondary sex characteristics. We describe a case of a patient with CGD in which CVST was the first manifestation of antiphospholipid syndrome (APS). A 49 years old 46, XY patient with CGD undergoing HRT was admitted to the emergency ward complaining of right sided, pulsating headache, nausea, vomiting and decreased visual acuity for the previous five days. Physical exam was unremarkable, without neurologic deficits. Blurred optic disc edges on ophthalmologic evaluation suggested increased intracranial pressure. Brain CT venography revealed thrombosis of the right lateral and left transverse sinus and filling defects of right internal jugular vein (IJV). Brain MRI confirmed right lateral sinus thrombosis, extending to right IJV. Treatment with low molecular weight heparin and acetazolamide was started with progressive symptomatic improvement. The patient was discharged after bridging to warfarin. An extensive hypercoagulable workup at presentation and 12 weeks later revealed a lupus anticoagulant (LAC) screen positive with DRVVT confirmation. No malignancy was identified in a whole-body CT-scan. HRT was stopped. CSVT is a multifactorial condition with gender-related specific causes. Despite the potential increased risk of venous thrombosis related with HRT and gonadal tumours in patients with CGD, we could not find in the literature any prior report of CSVT associated with this condition.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P6

Icon_pdf Download PDF

Poster


Acute ischemic stroke and severe bilateral internal carotid stenosis: a double dilemma - read full article

By: Bárbara Pedro, Marisa Mariano, Patrícia Ferreira, Jaime Pamplona, Ana Paiva Nunes, and João Reis

Background: Carotid artery stenosis is a significant cause of ischemic stroke with a high risk of recurrent vascular events. Carotid artery stenting (CAS) is a minimally invasive alternative to endarterectomy and has largely emerged as a treatment option over the past decade. Bilateral carotid artery stenting is generally treated by staged stenting procedure and rarely simultaneously. 
Clinical case: The authors report the case of a 73-year-old man with history of hypertension, dyslipidaemia and chronic alcohol intake, who acutely developed a left central facial palsy, dysarthria and left hemiparesis and hemihypoesthesia, scoring 21 points on the National Institute of Health Stroke Scale (NIHSS). Computed tomography (CT) showed no signs of acute vascular lesion. CT-angiography revealed occlusion of the right extracranial internal carotid artery (ICA) and additional middle cerebral artery (MCA) thrombus, at the M1 segment. Intravenous thrombolysis with rt-PA was started, and the patient was transported to the endovascular center. At admission he presented neurologic improvement (NIHSS17) and repeated CT that showed ischemic lesion on the right middle cerebral artery territory (ASPECTS 5). After the evaluation of the risks and the benefits, it was decided to perform cerebral angiography. This showed tandem occlusion of the proximal segment of right ICA (atherosclerotic plaque and thrombus) and occlusion of left distal ICA (intra-cavernous segment). Mechanical thrombectomy was performed and carotid stent was placed on the right ICA with satisfactory reperfusion - TICI 3. The patient was subsequently admitted to the stroke unit where he started double antiplatelet therapy with ticagrelor and aspirin. Close clinical monitoring showed neurologic improvement at 24 hours – NIHSS 6. Control brain CT was performed 24 hours later and showed infarct in the right MCA territory, as well as petechial haemorrhagic transformation. Carotid ultrasound confirmed severe left ICA stenosis with hemodynamic repercussion in the left ophthalmic artery and left MCA. On the third day after admission a brain MRI was performed and showed acute infarcts in the right middle cerebral artery territory, a left border-zone infarct and left hemispheric hypoperfusion. MRI-angiography revealed sub-occlusion of the left ICA. It was decided to perform left carotid artery stenting, followed by mechanical angioplasty with intra-stent balloon with satisfactory reperfusion. The neurosonological study was repeated and confirmed stents patency. The patient was discharged with neurological improvement (NIHSS 2) and maintained under double antiplatelet therapy. 
Conclusion: We would like to discuss the best management in this case, namely among the following options: maintain double antiplatelet therapy and close monitoring or proceed to endovascular (CAS) or surgical treatment of carotid stenosis immediately. We want to discuss the safety and efficacy of the bilateral CAS in patients with acute stroke.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P7

Icon_pdf Download PDF

Poster


Atrial myxoma—benign, but not harmless - read full article

By: Andreia M. Teixeira, Marta Soares Carreira, Luís Lemos, Margarida Matias, Leonor Dias, Marta Carvalho, Pedro Bernardo, Goreti Moreira, and Luísa Fonseca

Introduction: The incidence of stroke in young adults is rising. Different risk factors and pathologies can be present, increasing the difficulty in etiological investigation. Clinicians have to suspect about cardiac and vascular abnormalities, diverging from usual risk factors such as hypertension, diabetes, smoking and hypercholesterolemia. 
Clinical Case: A 37-year-old male, smoker, was assisted at the emergency room after an episode of presyncope and language disorder during a football game. He presented with tachycardia, normal blood pressure, and no changes on cardiac or pulmonary auscultation. On examination he had mild motor aphasia, minor motor deficit and hypoesthesia on the right leg. Brain computer tomography (CT) scan and CT angiography were performed, but no lesions were found. A transthoracic echocardiography identified a voluminous atrial mass (46x34mm) compatible with atrial myxoma, causing transmitral flow obstruction. The magnetic resonance imaging showed multiple ischemic lesions on the left medial cerebral artery territory, endorsing the possibility of cardioembolic aetiology. Surgical mass excision was performed. Histological examination confirmed the diagnosis. He recovered with no new symptoms or new lesions on brain CT scan after surgery. At the time of discharge, he still presented with minor aphasia. 
Conclusion: Myxomas are the most common primary cardiac tumours, but still, they are rare. Although they are benign, they can have significantly clinical implications, with a heterogeneous clinical course depending upon the characteristics of the mass. Early identification and prompt surgical removal can prevent catastrophic complications.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P8

Icon_pdf Download PDF

Poster


Subtleties on Patent Foramen Ovale closure - read full article

By: Elisa Martins Silva, Elisa Campos Costa, Ana Cláudia Ribeiro, Miguel Rodrigues, and Liliana Pereira

Background: Patent Foramen Ovale (PFO) closure is superior to medical treatment in secondary ischemic stroke prevention in highly selected patients. The presence of residual shunts can occur in 2–10%, and additional conditions that can result in right-left shunt (RLS) although uncommon, should be investigated. 
Clinical case: A 69-year old man, with previous medical history of hypertension, diabetes and chronic venous insufficiency, was admitted after multi-territorial transient ischemic attacks (TIAs) and recurrence of events under antiplatelet treatment. There were no signs of acute ischemia on MRI, atherosclerotic disease was excluded with carotid and transcranial ultrasound, and no relevant rhythm changes were found in a 24-hour Holter monitoring. The transcranial Doppler (TCD) revealed RLS, with a spontaneous shower pattern, and presence of PFO was confirmed with transoesophageal echocardiography (TEE). Paradoxical embolization was suspected due to presence of asymptomatic sub-segmental pulmonary embolism on lung scintigraphy, but venous thromboembolism was excluded on Doppler ultrasound. Thrombophilia work-up was negative and he was started on oral anticoagulation. Nevertheless, there was a TIA recurrence and urgent PFO closure was performed. The Risk of Paradoxical Embolism Score was only 2. Persistent RLS was found on 1 year-follow-up TEE from the left pulmonary vein. With TCD, only mild RLS subsided. No arteriovenous malformation was identified on thoracic CT. The patient was kept under oral anticoagulation, without new neurological signs. 
Conclusions: This case reports a situation where PFO closure was important despite failing current criteria for patient selection (older than 60 years, presence of comorbidities, no cortical infarct on imaging). Persistent RLS on follow-up raises the concern of incomplete closure or other sources of shunting. In this case, although an additional RLS source was found on TEE, no vascular events occurred and only mild shunting persisted on TCD.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P9

Icon_pdf Download PDF

Poster


Challenges of acute stroke treatment: when treating the brain is not enough - read full article

By: Miguel Quintas-Neves, Sofia Xavier, Carla Ferreira, Jaime Rocha, and José Manuel Amorim

A 51-year-old male was admitted in the emergency department with 6-hour evolution of left arm paraesthesia and left hemifacial palsy. Neurological examination revealed left visual and sensitive hemiextinction, left central facial paralysis and mild paresis of the upper left limb. Brain computed tomography (CT) and CT–angiography showed a subacute right frontoparietal hypodensity and right internal carotid proximal occlusion. Unsuccessful attempts were made to pass the occlusion with microguidewire and microcatheter. Left carotid angiogram showed contra-lateral compensation by a functional anterior communicating artery, despite delayed filling of the right middle cerebral artery. Severe stenosis of the left carotid cavernous segment was also found, for which best medical treatment was done. Brain CT at 24 hours confirmed a right peri-Rolandic infarct and excluded other complications. On the stroke unit, the patient developed a persistent anaemia, that was found to be associated with an active duodenal ulcer, partially treated by endoscopy due to its chronic nature. After a post-procedure period of severe agitation handled with sedation, the patient fully recovered to an unremarkable neurological state. However, sudden aggravation of the anaemia followed due to duodenal re-bleeding. Patient became comatose and brain CT showed bilateral ischemic lesions on multiple territories, leading to patient’s demise. The development of persistent hemorrhage due to refractory duodenal ulcer most probably led to brain hypoperfusion, inefficacious collateralization and severe brain ischemia. This case stresses the importance of effectively treating co-morbidities after an ischemic stroke and the potential burden of stenting in a patient with contraindication to antiplatelet therapy.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P10

Icon_pdf Download PDF

Poster


A big dilemma in a tiny patient - read full article

By: Catarina Perry da Câmara, Mariana Baptista, TeresaMorais, Fragata, Isabel, Carla Mendonça, José Pedro Vieira, and João Reis

Cerebral venous thrombosis (CVT) has an incidence of about 0.6/100.000/year in children, with male predominance. Of these, 30-50% of patients are newborn. Anticoagulation is the standard of care. An 8-day-old male, presented with excessive weight loss (17%), progressive anorexia and somnolence. There was no history of major complications during pregnancy or labour, except for gestational diabetes. At the emergency department, the patient was lethargic and physical examination revealed signs of dehydration, normotensive fontanel and no fever. The newborn was admitted to the neonatal unit with the suspicion of urinary infection and began treatment with antibiotics and IV fluids. Lab work showed elevated c-reactive protein (7mg/L) and hypernatremia (159mEq/L), with no leucocytosis. In the following day, after two episodes of tonic-clonic seizures, the MRI revealed extensive bilateral deep and superficial CVT, with signs of left hemisphere venous congestion. The patient started subcutaneous enoxaparin and was submitted to endovascular treatment. Arterial catheterization confirmed extensive CVT and after a venous approach, 4mg of recombinant tPA was administered directly into the thrombus in the superior sagittal sinus and mechanical thrombectomy was performed, with stent retriever. There was significant venous drainage’ improvement. Conclusion: Although endovascular treatment in cerebral venous thrombosis is not consensual and patient selection is controversial, it can be lifesaving.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P11

Icon_pdf Download PDF

Poster


Is alteplase still important in M1 occlusions undergoing thrombectomy? - read full article

By: Manuel Machado, Alberto Fior, Isabel Fragata, João Reis, and Ana Paiva Nunes

Introduction: Several randomized-controlled studies have shown the benefit of mechanical thrombectomy (MT) following intravenous thrombolysis (IVT). But nowadays, the utility of IVT before MT is being questioned. Two randomized-controlled studies are ongoing to address this question. Data available is conflicting. Some studies found no differences in functional outcomes while others found better outcomes, lower mortality, higher rates of successful recanalization in patients submitted to MT following IVT when compared with patients submitted to direct MT. 
Objectives: We aimed to compare patients with acute middle cerebral artery (M1) - occlusion treated with MT alone or with preceding IVT in a comprehensive stroke center in Portugal. Methods: Retrospective analysis of all registered M1 occlusions in our prospective database from January 2016 until June 2018.
Results: During this period, 669 thrombectomies were performed, and 263 were M1 occlusions. 157 patients were submitted to IVT followed by MT and 106 to MT alone (due to contraindications to perform IVT). Age, gender and baseline NIHSS were similar between the two groups. No significant differences were found in successful recanalization rates (Thrombolysis in Cerebral Infarction (TICI) 2b/3, 91.1% vs 93.3%, p=0.529), symptomatic haemorrhagic rates (3.2% vs 5.7%, p=0.333), and long-term favourable outcome (modified Rankin Scale 0–2, 41.2% vs 44.7%, p=0.580) between patients receiving MT plus IVT and those receiving MT alone. 
Conclusions: In our cohort, patients with M1 occlusions treated with IVT + MT have similar outcomes and complication rates when compared to MT-only treated patients. 

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P12

Icon_pdf Download PDF

Poster


Severe hypocalcemia manifesting as stroke - read full article

By: Eduarda Alves, Rafaela Pereira, Conceição Viegas, Giovanni Cerullo, Ana Paula Fidalgo, and Joana Pestana

Introduction: Hypoparathyroidism can occur after thyroidectomy which is correlated with several factors, such as the patient’s age, the extent of resection and surgeon's expertise. Neurologic disturbances after thyroidectomy are rare and caused by chronic hypocalcaemia resulting from iatrogenic hypoparathyroidism. The clinical presentation is variable, there are asymptomatic patients whose calcifications appears in imaging tests or with symptoms resulting from hypocalcemia. 
Clinical case: A 43-years-old woman with a history of hypoparathyroidism secondary to a thyroidectomy performed at 23 years of age, presents to the emergency department complaining of a sudden onset of left hemicranial headache, ipsilateral hypoesthesia of the body and face, transient motor aphasia, and amaurosis fugax of the left eye. Imaging studies were unremarkable for ischemic or haemorrhagic events, however several hyperdensities were present bilaterally throughout the basal ganglia, thalamus and deep cerebellar nuclei, suggestive of calcium accumulation. Blood chemistry revealed severe hypocalcaemia (4.6mg/dL) and hyperphosphatemia (6,9 mg/dL) which prompted immediate medical correction. Her family history is negative for calcium disorders. The patient was admitted for observation with the differential diagnosis of Fahr syndrome, transient ischemic attack or hypoparathyroidism, associated with severe hypocalcemia and cerebral calcifications. She was discharged after 8 days with complete recovery, and follow-up was scheduled in the outpatient clinic. 
Conclusion: Severe hypocalcemia can present stroke symptoms, but early detection allows for timely treatment and complete recovery. Fahr symdrome can´t be excluded but with the antecedents of the patient shouldn´t be considered as main diagnosis.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P13

Icon_pdf Download PDF

Poster


Thrombectomy: when should we stop? - read full article

By: Joana Branco Ferrão, Bruno Cruz Maia, and Ana Paiva Nunes

Endovascular treatment is an effective approach to acute stroke. Clinical assessment of eligibility to treatment includes neurologic examination, time of onset and imaging of brain parenchyma, large vessel patency and documentation of a mismatch in CT or MRI. Assessment of other hemodynamic criteria are usually not taken into account, namely the extent of collateralization. Different outcomes for thrombectomy treated patients are often observed and probably reflect discrepancies in collateral development in the acute phase. We present the case of a 64-year-old male patient, with prior medical history of hypertension, HIV-2 infection, and smoking habits, who presented at the emergency department with wax and waning neurological deficits of right hemiparesis, central facial palsy and dysarthria. NIHSS initially was 4 and shortly after increased to 8. No parenchymal lesion was noted on CT scan and CTA revealed an occlusion of the left internal carotid artery (ICA)on its cervical segment. Angiography was performed and confirmed left ICA occlusion on its origin by a thrombus. Intracranial circulation disclosed extensive collateral circulation, with middle cerebral artery receiving its main supply from the contralateral hemisphere via anterior communicating artery. At this point it was decided to not undergo treatment of the carotid occlusion. MRI performed on the next day was positive for an ischemic lesion on the left thalamus and carotid ultrasound also showed a thrombus on the origin of the left ICA. Significant clinical improvement occurred over the following days, with the patient being discharged with a NIHSS of 2. Antiplatelet therapy and optimization of vascular risk factors management was decided. On a 3-month follow-up, patient was asymptomatic. This case illustrates a good outcome on a patient with a large vessel occlusion stroke who was not treated with thrombectomy. Visualization of excellent collateral flow on angiography triggered the decision not to treat. Search for new clinical factors that may influence patient’s response to endovascular treatment is warranted and is an ongoing subject for discussion.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P14

Icon_pdf Download PDF

Poster


Indications for transoesophageal echocardiogram in the research of cardioembolic source for stroke - read full article

By: Inês Almeida, Joana Chin, Catarina Sousa, and João Tavares

Background: The identification of cardioembolic source (CES) in ischemic stroke is traditionally based on the use of transthoracic echocardiography (TTE). In selected cases, especially in the presence of doubtful findings in TTE or in the absence of etiological identification after extensive diagnostic testing, especially in young patients, transoesophageal echocardiography (TEE) may be important for a better morpho-functional cardiac characterization.
Objectives: Characterization of TEE results for CES identification in the context of ischemic stroke: identification of the existence and description of CES and profitability of TEE in this process. 
Methods: Retrospective analysis of patients´ data admitted with diagnosis of ischemic stroke in 2016, who performed TEE to clarify definite or probable CES identified in TTE. 
Results: 232 patients were admitted with a diagnosis of ischemic stroke, mean age 69.6 ± 11.9 years, 53.4% male. The most frequent co-morbidities were arterial hypertension (78%), dyslipidaemia (44.4%) and diabetes (34.5%). All patients underwent TTE and subsequently 8.2% of those underwent TEE, either due to findings in the TTE that were considered to deserve better characterization by TEE or persistence of a high suspicion of CES in the absence of another etiologic cause for stroke during the diagnostic process. Patients who had TEE had a lower mean age (60.5 ± 9.2 years), 52.6% female. One patient presented an intracardiac mass suggestive of vegetation versus fibroelastoma, the first hypothesis confirmed with TEE. The findings in the TEE were divided into two groups: definite and probable CES. The identification of cardiac vegetation was the only case in which a definite CES was found. In the remaining cases, 21.1% of the patients had simple atherosclerotic plaques in the aortic arch. In 5.3% each of the following situations were identified: presence of left atrial spontaneous auto-contrast, atrial septal aneurysm, atrial septal defect and patent foramen ovale. 
Conclusions: TEE, as an invasive and non-risk-free exam, should be reserved for patients in whom the suspected cardioembolic source remains elevated after a TTE and despite normal etiologic investigation. 

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P15

Icon_pdf Download PDF

Poster


Profitability of transthoracic echocardiogram in the identification of cardioembolic source for stroke - read full article

By: Inês Almeida, Joana Chin, Catarina Sousa, and João Tavares

Background: Ischemic stroke is one of the main causes of worldwide morbidity and mortality, with the identification of the underlying aetiology of great importance in order to prevent its recurrence. Cardioembolic sources (CES) are responsible for 20-30% of ischemic strokes, and transthoracic echocardiography (TTE) and 24 hours Holter are fundamental for its diagnosis. 
Objectives: Characterization of TTE results for CES identification in the context of stroke: identification and description of CES and profitability of TTE. 
Methods: Retrospective analysis of patient’s files, who underwent TTE to evaluate the presence of CES in the context of ischemic stroke during the year 2016. 
Results: 232 patients were evaluated, mean age 69.6 ± 11.9 years, 53.4% male. The most frequent co-morbidities were arterial hypertension (78%), dyslipidaemia (44.4%) and diabetes (34.5%). There is a known linear relationship between the left atrium area and the probability of atrial fibrillation / flutter (AF / FLA), this area was measured during TTE, the mean value was 18.5 ± 5.8 cm2 (normal value <20 cm2). Only 7.9% of patients had previous diagnosis of AF / AFL. The majority of patients had preserved global systolic function (mean ejection fraction 66.3 ± 13%, normal value> 50%). The findings in the TTE were divided into two groups: definite and indeterminate CES. Among the patients who presented definite CES, one patient presented an intracardiac mass suggestive of vegetation versus fibroelastoma, the first hypothesis confirmed with transesophageal echocardiography. 1.3% of the patients had mechanical valvular prosthesis in the mitral position, and the presence of thrombi in this location was excluded. No patient presented intracardiac thrombus, rheumatic mitral disease or cardiac tumour. Other potential CES with a modest risk of stroke (<2% / year) were relatively frequent echocardiographic findings, such as valvular disease, found in 64.2% of patients, with a documented presence of mild mitral insufficiency (26.7%), mild aortic insufficiency (24.1%) and mitral ring calcification (12.6%). In these situations, the causal relationship with stroke is not clearly established, being considered only possible risk factors, not altering the therapeutic behaviour. No patent foramen ovale, interatrial septum aneurysm, presence of spontaneous intracardiac contrast or left ventricular aneurysm were found. 
Conclusions: The identification of definite CES is fundamental for patient management, yet it occurs in a small percentage of cases, in our study only in 0.4%, in all other cases standard management is recommended.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P16

Icon_pdf Download PDF

Poster


Real world importance of 24-hours Holter in silent atrial fibrillation research - read full article

By: Inês Almeida, Joana Chin, Dinis Mesquita, and João Tavares

Background: The presence of atrial fibrillation or flutter (AF / AFL) is a well established cause of ischemic stroke, and its diagnosis is essential for the initiation of anticoagulation in patients with indication. Its diagnosis in the context of etiological investigation of stroke is usually based on 24-hour Holter (H24). 
Objectives: Evaluation of the execution and characterization of H24 results performed for silent AF / FLA screening in the context of ischemic stroke. 
Methods: Retrospective analysis of patients hospitalized during the year 2016 with the diagnosis of ischemic stroke who underwent transthoracic echocardiography and H24. 
Results: 232 patients were evaluated, mean age 69.6 ± 11.9 years, 53.4% male. The most frequent co-morbidities were arterial hypertension (78%), dyslipidaemia (44.4%) and diabetes (34.5%). 7.9% of the patients had previous diagnosis of AF / AF, of which 83.3% were under anticoagulant therapy. 44.4% of all patients underwent H24 during the etiological investigation of ischemic stroke, of which 59.2% were male, mean age 70.8 ± 10.9 years. In 86.4% of the exams no arrhythmia was detected, namely FA / FLA. Among the H24 that revealed arrhythmias: in 64.3% AF was detected throughout the H24 record, 14.3% paroxysmal AF, 14.3% atrial flutter throughout the registry and in 7.1% AF periods alternating with ventricular pacing rhythm. Of the patients with H24 showing dysrhythmia, in 10.7% of cases it was previously known, of which 72.7% were under anticoagulation at the time of stroke.
Conclusions: The screening of FA / FLA through H24 is of fundamental importance considering the therapeutic implications that it entails. Regardless of the arrhythmia identified (AF versus FLA) and verified daily load, anticoagulation is indicated, which in this context is the only therapy that demonstrates morbimortality reduction. We emphasize a significant number of patients not anticoagulated, despite having indication. 

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P17

Icon_pdf Download PDF

Poster


Pitfalls in suspected brain infarction—a Neuroradiologist’s must know - read full article

By: Luís Cardoso, Hugo Martins, Ricardo Martins, and Pedro S. Pinto

Introduction: A wide range of pathologies have been associated to restricted diffusion in the corpus callosum, particularly involving the splenium; those include seizures, drug therapy, infections, malignancy, metabolic disorders and others. In all these, increased levels of cytokines and extracellular glutamate lead to an influx of water into astrocytes and neurons. The water is trapped within the cells, resulting in intracellular oedema and low ADC value on MRI, a condition termed cytotoxic oedema. The neurons and glial cells of the splenium have higher density of cytokine, glutamate, drug receptors and others. 
Case presentation: A 39-year-old man with lung sarcoidosis under immunosuppression with corticoids; presented with progressive headache, drowsiness and weight loss. An inflammatory CSF with confirmed cryptococcus neoformans gave the diagnosis of CNS cryptococcosis. The patient developed a pattern of meningitis with vasculitis developing progressive ischemic lesions in small vessel territory. On MRI there were multiple lesions with diffusion restriction, including one centred in the splenium, symmetrical. The patient improved with treatment and on follow-up MRI there were multiple ischemic sequelae but not on the splenium. 
Conclusions: CNS cryptococcosis is associated to different pathological findings; one is the meningo-vasculitic pattern, with infarctions on small vessel territory. This patient presented a lesion in the splenium, which at acute phase is undistinguishable from true ischemia on MRI and might be interpreted as infarction. However, its location gives the clue, and the neuroradiologist should know that the splenium of corpus callosum is susceptible to very distinct alterations of the homeostasis and the findings on MRI are reversible in most cases.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P18

Icon_pdf Download PDF

Poster


What a Shunt!—a case of Patent Foramen Ovale - read full article

By: Ana Ponciano, Cátia Faria, Diana Moura, José Leite, and Célio Fernandes

Background: The presence of atrial septal defects or patent foramen ovale (PFO) is strongly associated with the presence of cryptogenic stroke especially in younger population. The mechanism by which atrial septal aneurysms contribute to brain embolism has not been satisfactorily clarified but these lesions can harbour thrombi. The authors present a case of patent foramen ovale in a young female. 
Case: A 36-year-old female presented in the emergency department with acute onset left hemiparesis and dysarthria. She was otherwise healthy, was under birth control with desogestrel and had a previous family history of stroke (her aunt had an ischemic stroke at 59-years of age). She gave birth to a healthy boy two years ago and had no previous history of miscarriage. A brain computed tomography (CT) with contrast was performed revealing an acute right insula infarct with evidence of thrombus in the right sylvian artery. However, after discussion with stroke team, neither thrombolysis nor thrombectomy was performed and the patient was admitted to further study. A magnetic resonance was performed confirming acute stroke and partial recanalization of the culprit vessel. The remaining study was unremarkable except for echocardiogram revealing atrial septal aneurysm and significant right-to-left shunt suggestive of PFO. She started anticoagulation and a PFO transcatheter closure was performed. She remained uneventful ever since. 
Conclusion: The available data regarding optimal treatment of PFO related strokes are inconclusive. The presence of both a PFO and an atrial septal aneurysm substantially increases the risk of stroke occurrence. Large defect, spontaneous right-to-left shunting, and large number of bubbles shunted may indicate a higher risk of paradoxical embolism. Anticoagulation and surgical or transcatheter closure are the available treatment strategies.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P19

Icon_pdf Download PDF

Poster


Subacute Blood-Brain Barrier Permeability after an Acute Ischemic Stroke is associated with Good Clinical Outcome - read full article

By: João André Sousa, César Nunes, Fernando Silva, Cristina Machado, Bruno Rodrigues, Gustavo Cordeiro Santo, Miguel Castelo Branco, Lino Ferreira, Luis Cunha, and João Sargento-Freitas

Background: The dynamics of blood-brain barrier (BBB) after an acute ischemic stroke (AIS) are complex and multiphasic. An early increase in permeability is associated with oedema, haemorrhagic transformation and poor clinical outcomes. Animal models indicate that a later, subacute stage of increased BBB permeability might have a positive effect representing neurovascular remodelling and neoangiogenesis. However, its clinical impact is still uncertain.
Objectives: To evaluate the association between BBB permeability at day 7 after an AIS and the patients’ clinical outcomes. 
Methods: We included consecutive patients with nonlacunar AIS in the territory of a middle cerebral artery with ages ranging from 18 to 80 years. We used modified Rankin Scale (mRS) score at 3 months as a measure of clinical outcome. Neuroimaging was performed at day 0 and 7 by Magnetic Resonance Imaging, including assessment of BBB permeability in the infarct lesion by dynamic contrast enhancement with quantification of the volume transfer coefficient (Ktrans). We performed an ordinal regression model between mRS and BBB permeability adjusting for the baseline variables associated with good outcome and including infarct volume as a covariate. 
Results: We included 45 patients; mean age was 70.0 ± 10.0 years. BBB permeability in the subacute stage showed a nonsignificant reduction in comparison with day 0: Krens: 0.0158 (SD: 0.0092) vs. 0.0163 (SD: 0.081), p=0.756. Permeability of BBB at day 7 was independently associated with improved clinical outcome (odds ratio 0.897; 95% confidence interval 0.816–0.986; p = 0.025). Inclusion of stroke volume in the regression model did not change statistical significance. 
Conclusion: We found subacute BBB permeability to be associated with good clinical outcome.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P20

Icon_pdf Download PDF

Poster


Isolated middle cerebral artery dissection, a rare cause of stroke - read full article

By: Luís Ribeiro, Pedro Bem, Sofia Monteiro, and Sandra Moreira

Introduction: Intracerebral arterial dissection (IAD) is a rarely observed stroke cause. 
Case Report: A 44-year-old male, Krav Maga instructor, without pathological history, was admitted at our emergency department after a transient episode of left upper limb (LUP) paresis that took five minutes to recover. He reported a similar episode of LUP paresis 7 days before, after Krav Maga training, with complete recovery after 30 seconds, accompanied by right temporo-parietal headache that lasted 2 days. At the emergency department his neurological exam was normal but his cerebral tomography (CT) revealed multiple hypodensities in the distal right middle cerebral artery (RMCA) territory. CT angiography showed M1-RMCA filiform stenosis. 2 days later, he underwent a cerebral magnetic resonance (MR) which revealed multiple superficial and deep hypersignal foci in RMCA territory with diffusion restriction. 3D TOF MR angiography showed incipient irregularities of signal intensity in M1-RMCA and transcranial Doppler revealed focal acceleration of flow velocity in that arterial segment (systolic velocity peak 265cm/s and stenosis/pre-stenosis index of 4.8). The biochemical, serological and immunological studies were unremarkable, besides dyslipidemia. The remaining investigation (transesophageal echocardiogram, Holter-EKG) was normal. Cerebral angiography, one month after admission, showed normalization of the RMCA caliber, without other changes. Thus, IAD, probably traumatic, was assumed to be the most likely diagnosis. The patient was discharged without neurological deficits with indication for dual antiplatelet therapy, high-intensity statin and high-impact sports deprivation. 
Conclusion: IAD's available literature is scarce, incidence and pathophysiology remain not fully understood.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P21

Icon_pdf Download PDF

Poster


The egg or the chicken: bilateral deep venous thrombosis and left thalamic stroke - read full article

By: Verónica Cabreira, Mariana Leal, Bernardo Moreno, and Joana Guimarães

Background: Thalamus is a transition nucleus, fundamental in several neuronal activities, including memory, language and mental alertness. It may be involved by vascular and inflammatory disorders, trauma, tumours and infections. 
Case report: 41-year old man with an unremarkable medical history started experiencing intense abdominal pain; nephrolithiasis was identified and opioid analgesics prescribed. Five days later, his wife notices speech slowness, disorientation, mood change and inappropriate behaviour and laughing. Despite arriving with his sister in law, he was unable to recognize her. Neurological examination disclosed a scarce speech with precipitate often wrong answers; working and recent memory, attention and abstraction were frankly compromised. He had no insight for his condition. Brain Computed Tomography scan revealed a left anterior thalamic lesion, with third ventricle moulding and no contrast enhancement; diffusion restriction pattern on brain magnetic resonance imaging identified it as a recent ischemic lesion. Six days after admission, he complained of intense bilateral calf pain which enabled him to walk. Bilateral leg deep venous thrombosis (DVT) was diagnosed and anticoagulation started. Both transoesophageal echocardiography and transcranial Doppler ultrasonography revealed a patent foramen ovale (PFO) with a significant right-left shunt. Autoimmune study was negative and a paraneoplastic cause was excluded. Thrombophilia screen is currently underway. 
Conclusions: PFO is frequently implicated in the aetiology of stroke, particularly in young patients with an apparent cryptogenic stroke. The suspicion about a paradoxical embolism mechanism was raised in this patient given the absence of vascular risk factors and concomitant unusual bilateral leg DVT.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P22

Icon_pdf Download PDF

Poster


Stroke and Air pollution: the effects of air quality in the number of ischaemic strokes in Lisbon - read full article

By: Filipa Proença, Lia Neto, João Madureira, Pedro Teotónio, Mário Mendonça, Carla Guerreiro, Francisco Raposo, Manuel Correia, and Graça Sá

Background: Stroke remains one of the leading causes of morbidity/mortality worldwide. Evidence from epidemiological studies has suggested an association between air pollution and ischaemic stroke, possibly related to increased blood coagulability and plaque rupture. The main air pollutants are particulate matter and gaseous pollutants, but the exact mechanism by which these pollutants promote stroke is poorly understood.
Objectives: To analyse the burden of the air quality levels in Lisboa/Vale do Tejo area and the number of endovascular treated-strokes in our center, between 2016-2018. 
Methods: Between 2016-2018, 449 ischaemic strokes were admitted for endovascular treatment, 397 from the Lisboa/Vale do Tejo area. The air quality level was retrospectively analysed and divided as Good-Bad (according to particulate matter and gaseous pollutants - Good: index very good and good; Bad: index medium, low and very low levels). This index was correlated with stroke cases, monthly and in the trimester before the event. 
Results: In all the trimesters, except the 4th trimester/2017, the trimestral peak number of treated-strokes matched the exposure to the worst air-quality months in the 3 months before the procedures. Endovascular thrombectomies were mostly performed during October/2016 and November/2017, which were also the second worst months of its years, regarding air quality. 
Conclusion: Air pollution is on par with “traditional” risk factors for cardiovascular disease and may have a close temporal association with ischemic stroke. Portugal’s global air quality index is currently far from optimal. A greater understanding of the genesis of this link and its true impact is important in order to improve public and environmental health policies.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P23

Icon_pdf Download PDF

Poster


Primary angiitis of central nervous system: diagnostic and therapeutic challenges - read full article

By: Francisco Bernardo, André Rêgo, Elsa Parreira, Rui Manaças, Ding Zhang, Martinha Chorão, and Amélia Nogueira Pinto

Primary angiitis of central nervous system (PACNS) is an uncommon vasculitis restricted to spinal cord and brain. Current diagnostic criteria for PACNS require newly acquired neurological deficit; specific angio¬graphic and/or histopathological features of angiitis within the CNS; and no evidence of an underlying sys¬temic disorder. In clinical practice, PACNS is frequently a diagnostic and therapeutic challenge. A 56-year-old man with a past medical history of hypertension and left lobar intracerebral haemorrhage, was admitted with an acute cognitive impairment. A brain MRI revealed multiple acute and chronic brain ischaemic lesions on different vascular territories. Digital subtraction angiography showed bilateral PCA and left ACA occlusions as well as multifocal segmental stenosis of both MCAs. CSF analysis revealed mild pleocytosis and elevated protein. A second brain MRI showed new subclinical posterior circulation ischaemic lesions with DWI restriction. Additional cardiovascular and systemic autoimmune workup were unremarkable. After brain biopsy we started five days of methylprednisolone followed by oral prednisolone. Although brain biopsy was negative for vasculitis, we maintained corticosteroids and added azathioprine. After three months of follow-up the patient remains clinically stable. A typical clinical picture and specific angiographic features of PACNS could be associated with a negative brain biopsy. Several questions remain unanswered and should be discussed. Can we skip brain biopsy before starting treatment? Should we maintain treatment in negative biopsy PACNS? Which is the best treatment for PACNS?

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P24

Icon_pdf Download PDF

Poster


Bridging therapy with IV thrombolysis versus mechanical thrombectomy alone in Acute Ischemic Stroke: a monocentric analysis of reperfusion rates - read full article

By: Inês Carneiro, Gonçalo Basílio, David Alves Berhanu, Manuel Correia, and Graça Sá

Background: Mechanical thrombectomy (MT) has been shown to be an effective treatment in patients with acute ischemic stroke (AIS) caused by large vessel occlusions (LVO). However, the additional effect of bridging therapy - intravenous thrombolysis (IVT) with recombinant tissue-plasminogen-activator (rt-PA) prior to endovascular therapy – compared with endovascular treatment alone remains controversial. 
Objectives: This study compared recanalization rates of endovascularly treated stroke patients with and without bridging IVT.
Methods: This monocentric retrospective observational study included data from patients with acute LVO within the anterior cerebral circulation who undergone MT with and without prior IVT between June 2017 and June 2018 in a comprehensive stroke center. Successful reperfusion was defined as a modified Thrombolysis in Cerebral Infarction (mTICI) scale 2b,2c and 3. Statistical analysis was carried out in IBM SPSS software. 
Results: One hundred and thirty patients with acute ischemic stroke in the anterior cerebral circulation that undergone mechanical thrombectomy were included. Bridging therapy was administered in 61.5% of the cases. Successful reperfusion was achieved in 80.8% of the total MTs. There was no significant association between the administration of IVT and successful reperfusion rate. 
Conclusions: Despite conflicting scientific evidence, data from our center provided indications towards the lack of advantage in reperfusion rates regarding bridging therapy prior to MT versus endovascular treatment alone. Further prospective studies are needed to confirm our findings, to identify patients that would most likely benefit from bridging therapy and to study the impact of rt-PA in patients’ functional outcomes.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P25

Icon_pdf Download PDF

Poster


An off-road cause of right eye hypovision - read full article

By: Luís Lemos, Maria João Pinto, Andreia Teixeira, Daniela Ferro, Margarida Matias, Paulo Castro Chaves, Jorge Almeida, and Luísa Fonseca

Introduction: Despite being a rare cause of stroke, cervical artery dissection (CAD) is an important cause of stroke accounting for 20% of strokes in young patients. 
Case Report: A 46-year-old man, owner of a gymnasium, with no pathological history and no usual medication, except sporadic protein supplements, presented to the emergency department with suddenly blurred vision and hypovision of his right eye. He denied recent physical activity, headache, neck pain or trauma but he performed some off-road tracks the day before. On examination he was hemodynamically stable with lower left nasal quadrant of the right eye hypovision in monocular confrontation. Brain CT had no acute lesions. The angio-CT revealed a marked but gradual reduction of the endoluminal filling immediately after the carotid bulb, with complete absence of filling from the proximal half of the cervical segment of the artery to the communicating segment. He started antiplatelet therapy with favourably progression. On the third day after admission he performed cerebral MRI and angio-RM that confirmed dissection of the right internal carotid artery, from the post-bulbar region to the proximal cervical segment, with no flow signal and contrast filling upstream to the ophthalmic segment, and no visualization of the proximal portion of the right ophthalmic artery. It was not possible to identify the unequivocal cause for the carotid dissection. The only possible cause identified was the off-road tracks. At discharge he still had left nasal quadrant hypovision of the right eye. 
Conclusion: In this case stands out the severe and extensive carotid lesion whose only symptom was hypovision of the lower left nasal quadrant of the right eye, without parenchymal lesion on MRI.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P26

Icon_pdf Download PDF

Poster


Endovascular treatment of Carotid Blowout Syndrome: Case Report - read full article

By: Catarina Pinto, Hugo Mota Dória, Luís Cardoso, and Ângelo Carneiro

Background: Carotid blowout syndrome refers to the rupture of carotid artery, being a rare and fatal complication in patients treated for head and neck cancer. Carotid procedures in previously irradiated neck are technically demanding and pose an increased risk of complications. Endovascular treatment with either permanent carotid occlusion or reconstructive stenting are good options. Objective: To present a carotid blowout syndrome treated with reconstructive stent graft. 
Clinical case: A 48 years old man, was diagnosed with hypopharynx cancer (epidermoid carcinoma cT4N2cM0) for what he has done chemotherapy and radiotherapy for 9 months. Revaluation CT one year after the diagnosis showed no signs of the disease. Three months after, he presents at Emergency Room with haemoptysis and hypovolemic shock. CT and CT-angiography scans showed infiltrative lesion of pharynx with necrosis and ulceration, revealing exposed left common and internal carotid arteries without contrast extravasion. In multidisciplinary discussion was decided to take the patient to the angio-room. The injection in the left common carotid artery showed a filling defect and concentric stenosis of the carotid bulb, that were successfully repaired using a covered stent graft in the common and internal carotid arteries. The stent was expanded using a balloon catheter for optimal coverage. The patient remained under dual antiplatelet therapy and was asymptomatic for 2 months, after what he re-started the haemoptysis. It was decided for expectant approach and the patient died 2 days after. 
Conclusion: The efficacy of endovascular treatment with stent versus carotid sacrifice for the carotid blowout syndrome is not well established. More studies are warranted to understand the best approach for these patients.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P27

Icon_pdf Download PDF

Poster


Recurrent ischemic stroke in young patient—discussion of a therapeutic approach - read full article

By: Leila Duarte, Cristiana Mendes, João Madeira Lopes, and J Meneses Santos

Introduction: Antiphospholipid syndrome and patent foramen ovale play an important role in the etiological investigation of ischemic stroke in young patients. The authors present a case of coexistence of these two factors and propose therapy based on the risk analysis of each of them. 
Clinical Case: 21-year-old white woman with personal history of cortical right parietal convexity ischemic stroke in 2015. In 2018, she reported three episodes of headache, paraesthesia, and decreased strength in the left upper limb with total resolution after a few hours, suggestive of transient ischemic stroke. Lab results showed positive 1/1280 ANA's with mottled pattern, anti-ds-DNA 1096.9 IU/mL and two positive tests of lupus anticoagulant, 12 weeks apart. She did an EEG with no epileptic activity. Brain CT and MRI scans revealed old right postcentral gyrus hypodensity, excluding new lesions. Transoesophageal echocardiography showed patent foramen ovale, absence of atrial septal aneurysm and left-right shunt. Transcranial Döppler ultrasonography did not reveal a shower pattern. Due to diagnostic criteria for antiphospholipid syndrome and without criteria for foramen ovale closure, the patient started warfarin. 
Discussion/Conclusion: The aetiology of ischemic events occurred in the clinical case described above was difficult to evaluate. However, the complementary tests for functional measurement of foramen ovale led to the conviction of its little etiological relevance, thus considering the antiphospholipid syndrome as decisive for the observed cerebral vascular pathology and as a consequence, the therapeutic proposal implemented.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P28

Icon_pdf Download PDF

Poster


Carotid stenosis grading: inter-observer agreement using CTA-NASCET - read full article

By: David Alves Berhanu, Carla Guerreiro, Francisco Raposo, Inês Carneiro, Paulo Sequeira, Rita Sousa, and Graça Sá

Background: Carotid artery stenosis is estimated to be responsible for approximately 10-15% of ischemic strokes. Patients with severe symptomatic stenosis benefit from revascularization therapy with endarterectomy or angioplasty and stenting. Revascularization is highly beneficial in patients with greater than 70% stenosis and may be beneficial in certain subgroups of patients with moderate stenosis of 50-69%. Measurement of internal carotid stenosis (ICA) to identify such patients can be made with computed tomography angiography (CTA) using the North American Symptomatic Carotid Endarterectomy Trial (NASCET) method. 
Objectives: Evaluate the reproducibility of the NASCET method between observers in patients with different grades of carotid stenosis and the possible impact of such variability on referrals to revascularization 
Methods: Thirty-seven cervical ICA measurements were obtained from a group of randomly selected patients who presented with acute stroke at a tertiary care hospital. CTA images were obtained using a 64-slice scanner and ICA stenosis was assessed using the NASCET method. Three neuroradiologists performed blinded measurements of the internal carotid arteries. We assessed inter-observer variability using the Cohen's kappa coefficient and Bland-Altman plots. 
Results: Significant agreement differences were found in the measurements obtained by the 3 observers. The kappa statistics (k<0,40) revealed a week-moderate inter-observer agreement. Correspondingly, differences were found in the categorisation of percentage of carotid stenosis, and correspondingly in which patients meet the criteria for referral to revascularization. 
Final Considerations: These findings suggest that the inter-observer variability of carotid stenosis grading using the NASCET method is not neglectable. The week-moderate agreement found suggests that strategies to increase accuracy of carotid stenosis measurement and evaluation using complementary methods may be necessary for correct referral of patients for revascularization.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P29

Icon_pdf Download PDF

Poster


First Pass Effect—Thrombus at first sight - read full article

By: Manuel Correia, Lia Neto, Francisco Raposo, Teresa Melo, Gonçalo Basílio, Paulo Sequeira, Luísa Biscoito, and Graça Sá

Background: In the treatment for acute ischemic stroke, it´s well established that earlier recanalization is associated with better outcome. It has been recently published the concept of the First-Pass-Effect (FPE), defined as achieving complete recanalization with a single pass of the thrombectomy device. This FPE could be a measure for predicting outcome. 
Objectives: Verify if the FPE could be a predictor of good outcome in the patients treated in our hospital. Methods: We retrospectively collected all the patients submitted to mechanical thrombectomy (MT) in our center in 2017-18. We selected the patients in whom we achieved TICI 3 (Thrombolysis In Cerebral lnfarction) and analysed the FPE, the NIHSS improvement and the clinical outcome modified Rankin Scale (mRS) score at 3 months. When 3mo-mRs was not available, the NIHSS decrease ? 4 points was used as a surrogate of good outcome. Finally, we verified if the FPE could predict good outcome. 
Results: During 2017-18 we performed 360 MT’s with recanalization TICI 3 in 113. The FPE was achieved in 63 patients, with faster procedures than in the other group. At 24 hours the FPE group had a greater decrease in NIHSS. At discharge and at 3 months evaluation there were significantly more patients with mRS?2 in the FPE group. 
Conclusions: These work shows the importance of fast opening the vessel, ideally in the first pass of the MT device, with patients achieving FPE being more independent. We should consider that in our center we don’t use the TICI 2C score, usually included in the FPE definition. This could have underestimated our results. With the growing experience of the neuro-interventionists and the improvement in devices, we will probably achieve better FPE rates, which would lead to even better outcomes.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P30

Icon_pdf Download PDF

Poster


Acute stroke endovascular treatment: ethical issues in decision making - read full article

By: Carla Guerreiro, Sofia Reimão, João Madureira, Lia Neto, and Graça Sá

Background: Endovascular therapy has emerged as a ground-breaking treatment for acute ischemic stroke, directly affecting emergency stroke management and resource distribution. In many cases, even with clear guidelines, the best action is uncertain and physicians must reflect on the classical ethical principles of beneficence, nonmaleficence, autonomy and justice to reach a wise decision. 
Objectives: To explore ethical dilemmas in acute stroke management, focusing on emergent endovascular treatment. Methods: Based on three clinical cases, we reviewed the classical principles of bioethics applied to stroke management. 
Results: 1. Autonomy and its limits A patient with dementia presented with less than 4 hours onset of aphasia and left-side hemiparesis. Pre-stroke disability in patients with advanced dementia is often an exclusion criterion for treatment. However, patients and relatives might consider retaining the pre-stroke status a favourable outcome. The principle of autonomy highlights a patient's (or proxy) right to participate in choosing treatment options. 2. Beneficence/ non-maleficence A patient with left M1 occlusion and critical internal carotid-artery stenosis, submitted to mechanical thrombectomy. Should we consider stenting the stenosis during the procedure? Uncertainty in treatment outcome hampers personalized decision-making in this setting, as haemorrhagic transformation risk may not be dismissible. The principle of non-maleficence is not absolute and balances with the principle of beneficence. 3. Distributive justice A patient with basilar artery occlusion under mechanical ventilation. Thrombectomy was unsuccessful. Only one bed available in the intensive care unit. How should we manage this patient? Distributive justice concerns the equitable distribution of scarce resources and their prioritization to specific areas and patients, many times in situations where prognosis is uncertain and patient’s wishes unknown. Such biases can lead to errors in decision making and to overuse/underuse of life-supporting measures. 
Conclusion: Difficult clinical settings where decisions are not straightforward will always subsist. Ultimately, high?quality care implies adhering to the basic principles of medical ethics, pondering scientific evidence and individual care.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P31

Icon_pdf Download PDF

Poster


Chiropraxy: friend or foe? - read full article

By: Rita Claro Santos, Sara Ventura, Bruno Maia, and Ana Paiva Nunes

Cervical trauma is a well-established cause for extracranial arterial dissection. However, there is a paucity of studies characterizing the type and intensity of trauma. A 40-year-old female presented to an outside hospital with complaints of right-sided weakness and paraesthesia. While at the emergency department she developed tetraparesis, nystagmus and anarthria. Previous history was unremarkable except for a session of chiropractic cervical manipulation that she had 1 hour before the first symptoms appear. CT had no lesions and CTA revealed an occlusive thrombus on the basilar artery. She was started on alteplase and transferred to our tertiary hospital for endovascular treatment. Angiography confirmed an occlusion of the basilar artery and showed a dissection of the left vertebral artery. Thrombectomy was performed with complete recanalization. She was admitted to the ICU and quickly extubated. In the next day, she had a complete recovery of her symptoms, remaining only a flattened nasolabial fold (NIHSS 1). MRI showed a small ischemic lesion of the pons. At discharge, she was started on antiplatelet therapy and patency of the vertebral and basilar arteries were demonstrated on doppler ultrasound. We have seen an increase in cervical artery dissections, in relation to recent chiropractic manipulations, affecting young patients with no other risk factors for cerebrovascular disease or concurrent history of trauma. As in our case, cervical dissection might be life-threatening, especially in the posterior circulation, raising the question if preventive measures and information about the dangers of chiropraxy should be targeted to the general population, as this practice becomes more common in our country.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P32

Icon_pdf Download PDF

Poster


Where do you live? The importance of the geographic location in the effectiveness of stroke management - read full article

By: Filipa Proença, Lia Neto, Manuel Correia, João Madureira, Pedro Teotónio, Mário Mendonça, Carla Guerreiro, Francisco Raposo, and Graça Sá

Background: For ischemic stroke time is brain and earlier recanalization is associated with better outcome. In 2016 the Lisbon Metropolitan emergency service for stroke was organized. In specific days, each of the 4 integrating hospitals is designated to receive patients and to perform endovascular thrombectomy (EVT) from the south of Portugal. 
Objectives: To evaluate in our center the different stroke management time-points for patients living far from Lisbon and its evolution in a four-year period. 
Methods: Between 2016-beginning of 2019 492 EVT were performed. 59 being far from Lisbon. This group was subdivided by years (2016-17 and 2018-19) and distance (70-100 km, 100-200km and 200-300km). Demographic characteristics, geographic location, stroke territory, type of transportation and the different time points regarding stroke management (symptom onset, first and second hospital admissions and recanalization time) were analysed. Results: From 59 EVT selected patients 24 were female, medium age 67 years, the majority (88%) with anterior circulation strokes. One quarter of the patients was in the 70-100km, 28% in the 100-200km and 47% in the 200-300km distance group, 9 transported by helicopter. In the farthest group the symptom onset-first admission time was always the worst. Regarding first admission-second admission there was a mild improvement in the 100-200 and 200-300Km groups, the opposite with the nearest hospitals. 
Conclusion: EVT in ischemic stroke must be performed as soon as possible. Regarding our center the different stroke management time points in patients far away from Lisbon are not optimal, although the slight improvement seen in 2018-2019 must be reinforced in order to ameliorate stroke management and outcome.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):P33

Icon_pdf Download PDF

Guest Editorial


Lisbon Stroke Summit 2019 - read full article

By: Ana Paiva Nunes and Elsa Azevedo

The Lisbon Stroke Summit reached its very successful third edition! We will keep the discussion on controversial topics of our everyday practice, reviewing rare conditions where evidence is far from real cases, and we will take a pick of the possible future of stroke medicine. Topics like artificial intelligence, precision medicine and stem cells, in line with a personalized medicine where individuality is considered for the best treatment strategy, are going to be discussed by top names in stroke medicine. This Summit is an effort to do better, to treat better, to understand better and to offer the possibility to discuss difficult clinical topics in an informal and pleasant way.

From the Lisbon Stroke Summit, Lisbon, Portugal. 5–6 April 2019.

International Journal of Clinical Neurosciences and Mental Health 2019; 6(Suppl. 1):S1

Icon_pdf Download PDF

Past issues

Thumb_ijcnmh.2016.3.1280
Issue 6 – 2019 - read full issue

Issue: 6 | 2019-01-29

Thumb_ijcnmh.2016.3.1280
Issue 5 – 2018 - read full issue

Issue: 5 | 2018-02-13

Thumb_ijcnmh.2016.3.1280
Issue 4 (2017) - read full issue

Issue: 4 | 2017-04-22

Thumb_ijcnmh.2016.3.1280
Issue 3 (2016) - read full issue

Issue: 3 | 2016-02-12

Thumb_ijcnmh.2014.1.480
Issue 2 (2015) - read full issue

Issue: 2 | 2015-02-10

Thumb_ijcnmh.2014.1.480
Issue 1 (2014) - read full issue

Issue: 1 | 2014-01-02