- Los Angeles, United States
Jeffrey L Saver
University of California, Los Angeles, Neurology, Faculty Member
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Acute, simultaneous, concomitant internal carotid artery (ICA) and middle cerebral arteries (MCA) occlusions almost invariably lead to significant neurological disability if left untreated. Endovascular therapy is frequently the method of... more
Acute, simultaneous, concomitant internal carotid artery (ICA) and middle cerebral arteries (MCA) occlusions almost invariably lead to significant neurological disability if left untreated. Endovascular therapy is frequently the method of treatment in such situations but there remains a chance of incomplete recanalization. Successful recanalization of the proximal aspect of the occlusion may allow for endogenous thrombolysis and facilitate further endogenous recanalization of any residual MCA occlusion. Consecutive patients with acute ischemic stroke undergoing endovascular therapy for tandem extracranial ICA-MCA or contiguous intracranial ICA-MCA occlusions were retrospectively analyzed. Rates of facilitated endogenous recanalization at 24 h (FER(24)) were compared by imaging within the immediate post-intervention 5-24 h period in those with proximal recanalization and in those without. 17 patients were included in the analysis. 12 patients had good initial proximal recanalization but a residual partial or total occlusion of the MCA while five patients failed any recanalization. Seven patients (58.3%) in the first group and none in the second had FER(24) on interval imaging after intervention (p=0.04). The probability of death and disability at discharge was less in patients with FER(24) than those without (p=0.05). More than half of all patients who present with both ICA and MCA occlusions who are only partially recanalized will undergo facilitated endogenous recanalization within the subsequent 24 h following intervention.
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Selecting among different antiplatelet strategies when patients experience a new ischemic stroke while taking aspirin is a common clinical challenge, currently addressed by a paucity of data. This study is an analysis of a prospective... more
Selecting among different antiplatelet strategies when patients experience a new ischemic stroke while taking aspirin is a common clinical challenge, currently addressed by a paucity of data. This study is an analysis of a prospective multicenter stroke registry database from 14 hospitals in South Korea. Patients with acute noncardioembolic stroke, who were taking aspirin for prevention of ischemic events at the time of onset of stroke, were enrolled. Study subjects were divided into 3 groups according to the subsequent antiplatelet therapy strategy pursued; maintaining aspirin monotherapy (MA group), switching aspirin to nonaspirin antiplatelet agents (SA group), and adding another antiplatelet agent to aspirin (AA group). The primary study end point was the composite of stroke (ischemic and hemorrhagic), myocardial infarction, and vascular death up to 1 year after stroke onset. A total of 1172 patients were analyzed for this study. Antiplatelet strategies pursued in study patients...
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To investigate the biological and functional significance of cerebral asymmetries, we measured lateral differences of the frontal and occipital poles on computed tomographic scans of 66 adult outpatients with no diagnosed abnormalities.... more
To investigate the biological and functional significance of cerebral asymmetries, we measured lateral differences of the frontal and occipital poles on computed tomographic scans of 66 adult outpatients with no diagnosed abnormalities. In addition to confirming the greater average sizes of the right frontal and left occipital poles, we found a significant linear correlation relating anterior and posterior difference measures. Men showed greater degrees of frontal and occipital asymmetries than women; reversals of the typical asymmetries were more common among women. Reduction or reversal of the usual left occipital predominance in the presence of typical right frontal predominance was associated with non-right-handedness. These findings clarify and extend prior qualitative observations and relate to the possible role of testosterone in modulation of cortical asymmetries. Reduced structural asymmetries among women and non-right-handers may provide an anatomical basis for clinical and laboratory findings of lessened functional lateralization in these groups.
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The NeuroDop is a new bedside assessment tool consisting of a continuous wave ultrasound probe attached to a stethoscope earpiece. This study was designed to compare middle cerebral artery (MCA) velocity assessment obtained with the... more
The NeuroDop is a new bedside assessment tool consisting of a continuous wave ultrasound probe attached to a stethoscope earpiece. This study was designed to compare middle cerebral artery (MCA) velocity assessment obtained with the NeuroDop versus standard transcranial Doppler (TCD). TCD technologists performed continuous wave NeuroDop studies followed by standard TCD studies on 60 subjects. Technologists recorded presence of MCA signal and estimated velocity based on NeuroDop auditory characteristics. Signal was obtained in 108 MCA vessels with the portable unit and in 112 vessels using standard TCD. For detection of patency, sensitivity was 96%, specificity 88%, positive predictive value 99%, and negative predictive value 58%. Auditorially estimated velocities from the NeuroDop strongly correlated with TCD velocity measures (r = 0.71). Categorical estimates of velocity as decreased (< 37 cm/sec), normal (37-81 cm/sec), or increased (> 81 cm/sec) demonstrated an accuracy rate of 85%. This novel stethoscope-continuous wave unit has excellent sensitivity in detecting presence of MCA patency. Moreover, MCA velocities can be characterized to a reasonable degree of accuracy based on NeuroDop auditory characteristics. The NeuroDop shows promise as a tool to rapidly assess and serially monitor presence and amplitude of MCA velocity and may help guide thrombolytic and other emergency management decisions in stroke patients.
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Ischemic stroke patients are at high risk for subsequent cardiovascular events. Despite this, an unacceptably high proportion of these patients do not receive treatment with evidence-based, guideline-recommended, vascular risk-reduction... more
Ischemic stroke patients are at high risk for subsequent cardiovascular events. Despite this, an unacceptably high proportion of these patients do not receive treatment with evidence-based, guideline-recommended, vascular risk-reduction therapies when exposed to conventional care. The golden opportunity to most favorably influence the vascular future of stroke patients is at the initial encounter in the hospital or in the postdischarge setting. As such, there has been profound interest in identifying effective strategies and systems that increase the use of evidence-based therapies in the hospital and outpatient settings, to reduce the substantial morbidity and mortality that can result from recurrent vascular events after stroke. One strategy is the implementation of a stroke hospitalization quality-improvement program geared at optimizing appropriate drug therapy before discharge, intensifying patient education, and ensuring vigilant follow-up with early recognition and management of problems. Available evidence suggests that hospital-based systems can markedly improve medical care and education of hospitalized ischemic stroke patients, and increase longer-term patient adherence in the community.
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The stroke patient who deteriorates presents a common and rewarding diagnostic challenge. Up to one third of ischemic stroke patients worsen after admission, though the frequency of deterioration is declining with modern supportive care.... more
The stroke patient who deteriorates presents a common and rewarding diagnostic challenge. Up to one third of ischemic stroke patients worsen after admission, though the frequency of deterioration is declining with modern supportive care. The causes of clinical worsening are diverse; common etiologies include collateral failure, brain edema, seizures, reocclusion after successful initial therapeutic recanalization, and systemic medical complications. Clot propagation and recurrent embolization are only infrequent mechanisms of worsening. The advent of multimodal computed tomography and magnetic resonance imaging has transformed the evaluation of the deteriorating stroke patient. History, physical examination, screening blood work, and emergent reassessment of the cervical and cerebral vasculatures, regional hypoperfusion, and infarct core will yield a firm diagnosis of the cause of clinical worsening in the majority of patients. The therapeutic armamentarium for the worsening stroke patient has expanded greatly. Treatment options now include rescue late endovascular recanalization therapy, pressor collateral enhancement therapy, hemicraniectomy, and additional novel interventions in addition to enhanced supportive care. Because most causes of worsening can be treated effectively, the deteriorating stroke patient merits a swift and incisive diagnostic and therapeutic response.
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ABSTRACT
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We examined a patient who exhibited Gerstmann's syndrome (left-right disorientation, finger agnosia, dyscalculia, and dysgraphia) in association with a perioperative stroke in the right parietal lobe. This is the first... more
We examined a patient who exhibited Gerstmann's syndrome (left-right disorientation, finger agnosia, dyscalculia, and dysgraphia) in association with a perioperative stroke in the right parietal lobe. This is the first description of the Gerstmann tetrad occurring in the setting of discrete right hemisphere pathologic findings. A well-localized vascular lesion was demonstrated by computed tomography, magnetic resonance imaging, and single-photon emission computed tomographic studies. The patient had clinical evidence of reversed functional cerebral dominance and radiologic evidence of reversed anatomic cerebral asymmetries.