1/18. Treatment of posterior circulation ischemia with extracranial percutaneous balloon angioplasty and stent placement.BACKGROUND AND PURPOSE: Vertebrobasilar territory ischemia (VBI) leads to disabling neurological symptoms and poses a risk for stroke by an embolic or flow-related mechanism. We present our clinical experience in the endovascular treatment of patients with symptomatic VBI from severe atherosclerosis or dissection of the vertebral and subclavian arteries that was unresponsive to medical therapy. methods: Twenty-one patients (9 female, 12 male) with a mean age of 65.7 years (range 47 to 81 years) underwent treatment with percutaneous endovascular balloon angioplasty and stent placement. Sixteen patients (76.2%) had evidence of contralateral involvement, and 9 (42.8%) demonstrated severe anterior-circulation atherosclerosis. Nine patients had a previous infarct in the occipital lobe, cerebellum, or pons before treatment. Follow-up was available for all patients. RESULTS: Balloon angioplasty with intravascular stent placement was performed in 13 vertebral artery lesions (10 at the origin, 3 in the cervical segment) and in 8 subclavian lesions. The prestenting stenosis was 75% (50% to 100%) and was reduced to 4.5% (0% to 20%) after stenting. Six of the patients with proximal subclavian stenosis demonstrated angiographic evidence of subclavian steal, which resolved in all cases after treatment. All patients showed improvement in symptoms after the procedure except for 1 who developed a hemispheric stroke after thrombotic occlusion of an untreated cavernous carotid artery stenosis (rate of major stroke and mortality=4.8%). One patient (4.8%) had a periprocedural transient ischemic attack (TIA), and none had minor stroke. At long-term follow-up (mean=20.7 /-3.6 months) of the surviving 20 patients, 12 (57.1%) remained symptom-free, 4 (19%) had at most 1 TIA over a 3-month period, 2 (9.5%) had at most 1 TIA per month, and 2 (9.5%) had persistent symptoms. There were no clinically evident infarcts during the follow-up period. CONCLUSIONS: Endovascular treatment using balloon angioplasty with intravascular stent placement for symptomatic stenotic lesions resulting in VBI that is unresponsive to medical therapy appears to be of benefit in this high-risk subset of patients with poor collateral flow.- - - - - - - - - - ranking = 1keywords = sclerosis (Clic here for more details about this article) |
2/18. Late hemorrhage from persistent pseudoaneurysm in vertebral artery dissection presenting with ischemia: case report.BACKGROUND: vertebral artery dissection lesions tend to resolve spontaneously, but abnormal findings such as aneurysmal-dilatation occasionally persist. However, the clinical features and pathological findings in such cases have never been verified. CASE DESCRIPTION: A 62-year-old man presented with left cerebellar infarction. angiography showed the "pearl and string sign" in the left vertebral artery, and he was diagnosed as having left vertebral artery dissection. Repeated angiography showed persistent aneurysmal dilatation with irregular stenosis. Eleven years after the cerebellar infarction, the patient presented with a subarachnoid hemorrhage from an aneurysm of the left vertebral artery, and the lesion was explored via the left suboccipital approach. The vertebral artery was firm, making the placement of a clip impossible, so the lesion was treated by coating of the bleeding point. The patient died of pneumonia and hyperglycemia on postoperative day 15. Postmortem examination revealed an organized intramural hematoma, thickening of the intima, and fibrous degeneration of the media of the vertebral artery, a fusiform, distended thin arterial wall with intimal disruption at the aneurysmal dilatation, and arteriosclerosis of all cerebral arteries. CONCLUSION: This case indicates that persistent aneurysmal dilatation of a dissection is a pseudoaneurysm prone to rupture, and that healing of the affected vessels might be severely compromised in the presence of pathological conditions such as arteriosclerosis and disturbed intraluminal blood flow in the dissected lesions.- - - - - - - - - - ranking = 1keywords = sclerosis (Clic here for more details about this article) |
3/18. Ischemic stroke. Clinical strategies based on mechanisms and risk factors.Ischemic stroke is a common disorder associated with significant morbidity and mortality. Results of several pivotal clinical trials completed within the last decade have helped refine stroke prevention and treatment strategies. endarterectomy for symptomatic carotid artery stenosis, anticoagulation in atrial fibrillation, and IV t-PA treatment of hyperacute ischemic stroke may reduce the burden of stroke. Ongoing studies are addressing newly recognized risk factors, such as aortic arch and intracranial atherosclerosis, as well as neuroprotective agents and locally delivered thrombolytics. Successful patient management requires a targeted clinical approach based on vascular localization and risk factor assessment.- - - - - - - - - - ranking = 0.5keywords = sclerosis (Clic here for more details about this article) |
4/18. Rapidly progressive stroke in a young adult with very low high-density lipoprotein cholesterol.Ischemic strokes can affect young adults (15-45 years old). Most such strokes are caused by cardioembolic events, small vessel disease, or illicit drug use, and less frequently by large vessel atherosclerosis. Large vessel cerebral atherosclerosis is usually associated with high levels of low-density lipoprotein (LDL) cholesterol, but a low level of high-density lipoprotein (HDL) is also a risk factor for ischemic strokes. The magnitude of increased risk is unclear, particularly with extremely low HDL levels found only in various genetic and inherited disorders. Advanced atherosclerosis developed in the patient in this study, with HDL of 3 mg/dL, leading to rapidly progressive stroke with a fatal outcome. The disease primarily affected the posterior circulation. The course of this case illustrates that very low HDL may be associated with advanced cerebrovascular atherosclerosis and fatal stroke, and as such should be considered in young individuals with stroke.- - - - - - - - - - ranking = 2keywords = sclerosis (Clic here for more details about this article) |
5/18. case reports on emergency treatment of cardiovascular syndromes through heparin-mediated low-density lipoprotein/fibrinogen precipitation: a new approach to augment cerebral and myocardial salvage.We report the first experiences with HELP apheresis as an emergency treatment for acute cardiovascular syndromes; two patients who were not eligible for lysis therapy and catheter intervention were treated with HELP apheresis instead. Both patients had a most severe, generalized atherosclerosis and reached the hospital too late for conventional measures. In both cases, the use of the apheresis dramatically improved the clinical situation to such an extent that the possibilities of this apheresis system urge further investigation.- - - - - - - - - - ranking = 0.5keywords = sclerosis (Clic here for more details about this article) |
6/18. Ischaemic stroke in progressive systemic sclerosis.Progressive systemic sclerosis (PSS) or scleroderma is a multisystem disease affecting the skin, lungs, myocardium, kidneys and gastrointestinal tract. Primary involvement of cerebral arteries in PSS has been reported but is very rare. A 61-year-old woman suffering from scleroderma for six years was hospitalised for two subsequent episodes of transient acute dysarthria and left hemiparesis. After five hours from the first onset of symptoms, she was submitted to brain magnetic resonance (MR) protocol that showed a right subinsular ischaemic lesion and whole right middle cerebral artery (MCA) territory hypoperfusion. Intracranial and epiaortic MR angiography reported a focal stenosis in the M2 portion of MCA. She was immediately treated with i.v. high dose steroids and oral acetylsalicylic acid. At one-month follow up, MR findings were confirmed. We have documented a cerebral infarct in a PSS patient. In our opinion, the ischaemic stroke was caused by a localised autoimmune angiopathy.- - - - - - - - - - ranking = 2.5keywords = sclerosis (Clic here for more details about this article) |
7/18. Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy: an imaging mimic of multiple sclerosis. A report of two cases.OBJECTIVE AND IMPORTANCE: To describe the imaging findings of two cases of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (cadasil) mimicking multiple sclerosis. CLINICAL PRESENTATION AND INTERVENTION: Two cases presenting with neurological signs and symptoms were referred for magnetic resonance imaging (MRI) evaluation of the brain. Case 1 was a 36-year-old female patient presenting with recurrent headaches and recent onset numbness in the fingers of the right hand. Neurological examination showed a mild sensory deficit in the right hand. Case 2 was a 31-year-old female patient presenting with attacks of right-sided numbness of the face and body. The neurological examination revealed a sensory loss in the face and brisk deep tendon reflexes. Routine MRI sequences showed two types of lesions in both cases: 'punctate' hyperintense lesions on T(2)-weighted images (T(2)WI)/fluid-attenuated inversion recovery (FLAIR) images, hypointense on T(1)-weighted images (T(1)WI) and 'diffuse' white matter lesions, hyperintense on T(2)WI/FLAIR sequences and isointense to hypointense on T(1)WI. All lesions showed no contrast enhancement. Both cases were previously clinically and radiologically diagnosed as multiple sclerosis. There was a strong family history consistent with recurrent infarctions in other family members of both patients. Both cases were later diagnosed as cadasil by skin biopsy/genetic linkage studies and follow-up. CONCLUSION: The cases showed that cadasil causes stroke-like episodes in adults and can mimic multiple sclerosis on imaging. Clinical evaluation and MRI findings allow a differentiation of the two entities.- - - - - - - - - - ranking = 26.921895521806keywords = multiple sclerosis, sclerosis (Clic here for more details about this article) |
8/18. Ischemic encephalopathy in ANA-negative systemic lupus erythematosus.A woman with a nine-year history of Raynaud's phenomenon developed photodermatitis and a sudden neurological syndrome characterized by transient focal disorders accompanied by wide and persistent cerebral lesions demonstrated by CT, NMR and SPECT imaging. A careful evaluation of the clinical manifestations of neurological SLE along with the detection of anti-Ro/SSA antibodies prompted us to reconsider the diagnosis of SLE. Moreover, the discrepancy observed between the poor neurological picture and the widespread encephalic alterations shown by CT, NMR and SPECT imaging suggests that it may be useful to conduct these investigations in patients affected by SLE with modest neurological signs and symptoms. A further interesting aspect of this case is represented by the differential diagnosis with two other diseases, such as Sneddon's syndrome and multiple sclerosis, which are characterized by the presence of certain clinical and instrumental findings also observed in neurological SLE.- - - - - - - - - - ranking = 3.8459850745437keywords = multiple sclerosis, sclerosis (Clic here for more details about this article) |
9/18. Computerized tomographic findings and differential diagnostic considerations in subcortical arteriosclerotic encephalopathy (Binswanger's disease).This paper discusses the conditions which may be associated with diffuse periventricular hypodensity on CT. Of these conditions, subacute arteriosclerotic encephalopathy (Binswanger's disease) is a common differential diagnostic consideration. This condition results from ischemic demyelination with loss of axons and astrogliosis. CT usually shows diffuse bilateral confluent hypodensities in the cerebral white matter. This is most prominent and seen earliest in the periventricular region and may extend more diffusely into the centrum semiovale. It is important to differentiate this condition from normal pressure hydrocephalus and primary nonischemic demyelinating disease (multiple sclerosis).- - - - - - - - - - ranking = 3.8459850745437keywords = multiple sclerosis, sclerosis (Clic here for more details about this article) |
10/18. Acute pseudobulbar mutism due to discrete bilateral capsular infarction in the territory of the anterior choroidal artery.Pseudobulbar mutism is rarely attributed to bilateral discrete posterior limb internal capsule-medial globus pallidus infarction. Few cases of bilateral anterior choroidal (AchA) artery territory infarction have been reported. We present 8 patients with ischaemic stroke in this location and vascular distribution who have a characterizable syndrome. All had the abrupt onset of inability to speak, swallow or phonate, accompanied by varying degrees of facial diplegia, hemiparesis, hemisensory loss, lethargy, neglect and change in affect. The appearance of clinical signs depends upon the presence of a new infarct contralateral to an older lesion in mirror position. The pathogenesis and progression of neurological deficit appears to be intimately related to hypertension. The role of intrinsic intracranial vascular pathology related to diabetes mellitus, embolism of cardiac origin and atherosclerosis is currently undefined. The prognosis for recovery is poor. Half of our patients died within a year of onset of symptoms. Capsular pseudobulbar mutism is recognized by the abrupt appearance of neurological deficit consistent with internal capsular pathology and is confirmed by CT scan or MRI.- - - - - - - - - - ranking = 0.5keywords = sclerosis (Clic here for more details about this article) |
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