BackgroundEndovascularly retrieved clots are a potential resource for diagnosing stroke etiology, which may influence secondary prevention treatment. In this study we measured thrombin activity eluted by serially washing clots.MethodsClots were retrieved from 68 patients with acute ischemic stroke, freshly frozen and classified by standard criteria into proven atrial fibrillation (AF, 18 patients), atherosclerotic origin (AS, 15 patients), cryptogenic stroke (Cr, 17 patients) and other known causes (18 patients). Thawed clot samples were washed by transferring them into 1 mL buffer in seven hourly cycles and a fluorescent substrate assay was used to measure secreted thrombin activity. The clots were also examined histologically. Artificial fibrin and red blood cell-rich clots were similarly assayed for wash-eluted thrombin activity as an external control.ResultsThrombin activity eluted from clots of AF origin decreased significantly with time in contrast to steady levels eluted from AS origin thrombi (P<0.0001 by repeated measures ANOVA). The Cr stroke group was indistinguishable from the AF group and differed statistically from the AS group (P=0.017 by repeated measures ANOVA). In artificial clots we found a biphasic activity pattern, with initially decreasing levels of eluted thrombin (AF pattern) and then, with continuing washes, steady eluted thrombin levels (AS pattern).ConclusionsAn assay measuring the change in thrombin in clots retrieved during acute stroke endovascular thrombectomy procedures may serve as a diagnostic marker of the origin of the clot. The suggested mechanism for these differences may be the clot location before its retrieval, with high blood flow causing thrombin washout in atherosclerotic clots, in contrast to atrium appendage low blood flow retaining high thrombin levels.
Objectives: This is a case series and a review of the literature of therapeutic outcomes of botulinum toxin (BT) injections for anterocollis.Methods: Data collected included gender, age, age at onset, muscles targeted, and doses injected. Routine forms were filled out during each visit: Patient Global Impression of Change, Clinician Global Impression of Severity, Tsui scale. The effect duration and side effects (SEs) of the previous treatment were noted. Results:We described 4 patients (3 men, 13 visits) with anterocollis, as primary postural abnormality of the neck, emphasizing the therapeutic response to BT injection. Mean age at onset was 75.3 ± 7.0 years, age at first injection was 80.7 ± 3.5 years. The mean total dose per treatment was 290.0 ± 95.6 units. Patient Global Impression of Change with any grade of favorable effect was reported in 27.3% of the treatments. In objective assessment, Global Impression of Severity and Tsui scores did not show a consistent tendency of improvement. Neck weakness was prevalent in 18.2% of the visits of the anterocollis group while no other SEs were noted. We found 15 articles describing experience with BT for anterocollis in 67 patients (19 in deep and 48 in superficial neck muscles).Conclusions: This case series describes the poor outcome of BT treatment for anterocollis, with low efficacy and bothersome SE. Levator scapulae injection for anterocollis is not effective and is highly associated with head drop and should perhaps be abandoned. Injection to the longus colli might give some benefit in non-responders.
Introduction: Systemic Thrombolysis with tissue Plasminogen Activator (tPA) has been an established therapy for ischemic stroke for more than 20 years, with limited effect on large vessel occlusions. New catheter-based techniques allow high revascularization rates were tPA fails. Systemic thrombolysis remains the standard treatment of care and endovascular treatment is newly established as therapy for large vessel occlusion or rescue therapy after unsuccessful revascularization by thrombolysis. Patients with large vessel occlusions have a very limited reperfusion rate and benefit from direct endovascular treatment (EVT). In this real-life study, patients are compared regarding their outcome after systemic thrombolysis with rescue endovascular treatment in comparison to direct endovascular treatment for large vessel occlusions. Patients and Methods: Patients are categorized retrospectively by their treatment. Data on 120 patients was used, with the exclusion of 13 patients. Analyses were performed according to mRS and EQ5D after 7 days as well as 10 to 14 weeks. Primary observed outcome was quality of life and mRS after 10 to 14 weeks. Results: Regarding mRS, initial outcome after 7 days is more successful with direct EVT, but prior thrombolysis shows additional improvement after 10 to 14 weeks. There is no statistically relevant difference in patients that received prior tPA and rescue endovascular treatment in comparison to direct endovascular treatment after 10 to 14 weeks. EQ5D on the other hand shows higher life quality, according to better functional outcome after endovascular treatment. Regarding the primary endpoint of the study, there is no statistically relevant difference between both study groups at the end point of the study. Discussion: While direct endovascular treatment shows an immediate benefit for patients with large vessel occlusions, over the time course of 10 to 14 weeks there is a higher additional benefit for prior thrombolysis treatment. Regarding that, both treatment arms show a similar outcome. A higher life quality regarding EQ5D is archived after direct EVT while judgement for general ability is rated higher with additional tPA treatment. Conclusion: In this mono-center study it was shown that patients eligible for thrombolysis with large vessel occlusions should receive tPA if eligible. By lack or insufficient improvement, a rescue endovascular treatment should be applied. Direct endovascular treatment shows a similar outcome regarding mRS but a higher life quality index.
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