- Email: [email protected]
Brain imaging in patients with transient ischemic attack
e464
Abstracts / Journal of the Neurological Sciences 357 (2015) e457–e512
Neuroimaging has revolutionised our approach to stroke therapy. For ischaemic stroke MRI has been the mainstay over recent decades because of the extraordinary amount of information which can be generated ranging from mismatch, vessel status through to metabolic parameters. After initial problems with threshold values (or lack thereof) MR mismatch as a signature of viable tissue and a target for therapy has become established in recent trials. However, CT perfusion (CTP) has now superseded MR because of the automatic co-registration of viable versus non-viable tissue, the generation of angiographic data and including the status of vessel co-laterals. Importantly, CTP is more widely available, can be performed within a shorter timeframe and is not plagued by MR limitations of claustrophobia and other contra indications to use. There is a reasonable argument that CTP should be standard initial imaging modality because of its features outlined above and its usefulness in acute intra cerebral haemorrhage to identify patients at risk of haematoma expansion with the spot sign and exclusion of underling AVMs. The recent finding that contrast induced nephropathy is inconsequential when sensible pre-scan clinical screening is undertaken is reassuring. Automated software such as RAPID also makes CTP an appealing and pragmatic stroke imaging tool within the therapeutic decision making framework.
doi:10.1016/j.jns.2015.09.170
1597 WFN15-1843 Stroke MT 3.2 - New opportunities for Management of Acute Stroke Reperfusion strategies, proven, disproven and uncertain P. Ringleb. Neurology, University hospital Heidelberg, Heidelberg, Germany Reperfusion strategies, proven, disproven and uncertain Peter A. Ringleb Reperfusion of occluded vessel is a major topic of acute stroke treatment for decades. First experiences were done in the 1980 with intra-arterial medical thrombolysis. This was followed by intravenous rtPA treatment in the 1990s, because it is much easier to deliver to a relevant cohort of patients. However recanalization rate of especially large vessels like Carotid-T, proximal MCA or Basilar artery with iv-rtPA is limited. Hence, several mechanical devices for recanalization of intracranial vessel occlusions have been developed for more than a decade and were approved for clinical use on the basis of uncontrolled case series. First randomized clinical trials comparing the new devices with standard treatment, including thrombolytic therapy, failed. After these negative results several new trials with changes in design (e.g. shorter time window and only proximal vessel occlusions) and the use of modern devices like stent-retrievers have been launched. In October 2014 the first of these new trials was presented and showed a clear superiority of thrombectomy. Based on this result interim analyses of five other studies were performed and most were prematurely terminated because of overwhelming efficacy. Currently five studies have already been published and two more studies have been presented at scientific conferences. This talk will give an overview about the recanalization trials and will especially provide a discussion for which clinical situation evidence for superiority of mechanical thrombectomy still is lacking.
doi:10.1016/j.jns.2015.09.171
1598 WFN15-1858 Stroke MT 3.2 - New Opportunities for Management of Acute Stroke Management of acute intracerebral hemorrhage – when to start and how to treat C. Anderson. Neurological and Mental Health Division, The George Institute for Global Health, Camperdown, Australia Hypertension is common in all types of acute stroke, but whether prompt lowering of BP provides benefits without excessive risk has been a matter of longstanding controversy … until recently. The Intensive Blood Pressure Reduction in Acute Intracerebral Haemorrhage (ICH) Trial (INTERACT2) provides important new evidence of the efficacy and safety of early intensive BP lowering in ICH, where management of this condition has been largely supportive, and often nihilistic, in the absence of a proven treatment. The INTERACT2 results, together with other trial and observational data, has pushed guideline recommendations and clinical practice around the world towards more aggressive management of BP (towards a systolic target of b140 mmHg) rather than the conventional level of control (b180 mmHg). Further trial data also highlights the importance of early and smooth control of systolic BP, not just in the first 24 hours but over the subsequent several days after ICH. The effectiveness of early intensive BP lowering in routine clinical practice will depend on better understanding the barriers and facilitators of changing systems for delivering such care using streamlined protocols and quality improvement strategies. Planned extensions of INTERACT2 include studies of very early pre-hospital paramedical initiation of BP lowering therapy and multifaceted Health Systems Intervention strategies designed to reconfigure systems of care to enhance delivery of early BP lowering treatment across a range of health care settings. Effective implementation of complex interventions requires system changes in clinical practice. doi:10.1016/j.jns.2015.09.172
1599 WFN15-1856 Neuroimaging MT 9.2 - Cerebrovascular Imaging Brain imaging in patients with transient ischemic attack F. Purroy. Stroke Unit. Clinical Neurosciences Group, Hospital Universitari Arnau de Vilanova. IRBLleida, Lleida, Spain Since the new tissue definition of transient ischemic attack (TIA), diffusion weighted imaging (DWI) has become essential for the management of patients with transient neurological symptoms. Despite transient of symptoms up to one out of three patients had acute ischemic lesions. But, what is more important, classically defined TIA patients (duration of symptoms less than 24 hours) who have abnormalities on DWI have a higher risk of early recurrent ischemic events than those without such abnormalities. It has been demonstrated how the incorporation of neuroimaging data in the clinical prognostic scores, like ABCD2 score, improves its predictive power. Furthermore, not only the presence of acute ischemic lesions but also the pattern of distribution matters. Patients with scattered lesions due to large artery atherosclerosis have the highest risk of stroke recurrence. Moreover, perfusion imaging with perfusion MRI or CT perfusion may improve the detection of ischemic lesions. The combination of DWI and perfusion MRI can document the presence of a cerebral ischemic lesion in approximately half of all patients. Finally, other neuroimaging parameters different from DWI, such us
Abstracts / Journal of the Neurological Sciences 357 (2015) e457–e512
e465
the presence cerebral microbleeds, have emerged as novel predictors of stroke recurrence.
doi:10.1016/j.jns.2015.09.173
1600 WFN15-1794 Neurological Infections MT 12.2 - Parasitic and Fungal Disorders Neurocysticercosis A. Carpio. School of Medicine, University of Cuenca, Cuenca, Ecuador Neurocysticercosis (NC), the most common parasitic brain disease worldwide, is still a cause of unacceptable morbidity and mortality in endemic areas and is an emerging public health problem in high-income countries. Its clinical heterogeneity is related to localization, number and stage of evolution of the parasites, gender, age and intensity of the host brain inflammatory reaction.. In Inflammation is the main phenomenon responsible of symptomatology. Control of the inflammatory reaction in NCC is under debate today: it can surely reduce frequency of some complications, but it can also contribute to the poor clinical evolution of some patients. Acute symptomatic seizures are the most common symptom in patients with parenchymal parasites, but most do not evolve into epilepsy. Co-existence of cysticercus antibodies does not necessarily imply causation of epilepsy. Because of the high prevalence of each condition in developing countries, a causal as well as fortuitous relationship between the two pathologies might exist. NC diagnosis is based mainly on neuroimaging. New imaging techniques have improved detection of the scolex and visualization of cysts in the CNS. Immunological testing could be useful, particularly when imaging is equivocal. A study to assess the reliability, sensitivity and specificity of new set of diagnostic criteria is currently under way, which might allow early detection of, and differentiation between, parasites located in the parenchyma or in the extraparenchymal compartments. Based on disappearance of parasites, antihelminthic drugs as currently used are effective in approximately one third of patients with parenchymal viable cysts.
doi:10.1016/j.jns.2015.09.174
1601 WFN15-1873 Neurological Infections MT 12.2 - Parasitic and Fungal Disorders Trypanosomiasis M. Bentivoglio. Dept Neurological and Movement Sciences, University of Verona, Verona, Italy Nervous system infections caused by the flagellate protozoan trypanosomes include American trypanosomiasis or Chagas disease, caused by the intracellular Trypanosoma cruzi, transmitted by many species of triatomine bugs, and human African trypanosomiasis (HAT), also called sleeping sickness, caused by the extracellular Trypasonoma brucei, inoculated through bites of tsetse flies (genus Glossina). During its chronic phase T. cruzi infection attacks mainly the autonomic nervous system, with heart and gastrointestinal tract denervation. Chagas disease, which is highly invalidating, remains a public health issue in Latin America despite recent progress in vector control. In HAT, the first, haemolymphatic stage evolves into the second, meningoencephalitic stage, targeting the central nervous system when parasites cross the blood-brain barrier. HAT, which has two forms caused by T. brucei gambiense and rhodesiense, respectively, has a focal distribution in sub-Saharan Africa, mostly in resource-poor and politically unstable settings. Both forms of HAT
Abstracts / Journal of the Neurological Sciences 357 (2015) e457–e512
Neuroimaging has revolutionised our approach to stroke therapy. For ischaemic stroke MRI has been the mainstay over recent decades because of the extraordinary amount of information which can be generated ranging from mismatch, vessel status through to metabolic parameters. After initial problems with threshold values (or lack thereof) MR mismatch as a signature of viable tissue and a target for therapy has become established in recent trials. However, CT perfusion (CTP) has now superseded MR because of the automatic co-registration of viable versus non-viable tissue, the generation of angiographic data and including the status of vessel co-laterals. Importantly, CTP is more widely available, can be performed within a shorter timeframe and is not plagued by MR limitations of claustrophobia and other contra indications to use. There is a reasonable argument that CTP should be standard initial imaging modality because of its features outlined above and its usefulness in acute intra cerebral haemorrhage to identify patients at risk of haematoma expansion with the spot sign and exclusion of underling AVMs. The recent finding that contrast induced nephropathy is inconsequential when sensible pre-scan clinical screening is undertaken is reassuring. Automated software such as RAPID also makes CTP an appealing and pragmatic stroke imaging tool within the therapeutic decision making framework.
doi:10.1016/j.jns.2015.09.170
1597 WFN15-1843 Stroke MT 3.2 - New opportunities for Management of Acute Stroke Reperfusion strategies, proven, disproven and uncertain P. Ringleb. Neurology, University hospital Heidelberg, Heidelberg, Germany Reperfusion strategies, proven, disproven and uncertain Peter A. Ringleb Reperfusion of occluded vessel is a major topic of acute stroke treatment for decades. First experiences were done in the 1980 with intra-arterial medical thrombolysis. This was followed by intravenous rtPA treatment in the 1990s, because it is much easier to deliver to a relevant cohort of patients. However recanalization rate of especially large vessels like Carotid-T, proximal MCA or Basilar artery with iv-rtPA is limited. Hence, several mechanical devices for recanalization of intracranial vessel occlusions have been developed for more than a decade and were approved for clinical use on the basis of uncontrolled case series. First randomized clinical trials comparing the new devices with standard treatment, including thrombolytic therapy, failed. After these negative results several new trials with changes in design (e.g. shorter time window and only proximal vessel occlusions) and the use of modern devices like stent-retrievers have been launched. In October 2014 the first of these new trials was presented and showed a clear superiority of thrombectomy. Based on this result interim analyses of five other studies were performed and most were prematurely terminated because of overwhelming efficacy. Currently five studies have already been published and two more studies have been presented at scientific conferences. This talk will give an overview about the recanalization trials and will especially provide a discussion for which clinical situation evidence for superiority of mechanical thrombectomy still is lacking.
doi:10.1016/j.jns.2015.09.171
1598 WFN15-1858 Stroke MT 3.2 - New Opportunities for Management of Acute Stroke Management of acute intracerebral hemorrhage – when to start and how to treat C. Anderson. Neurological and Mental Health Division, The George Institute for Global Health, Camperdown, Australia Hypertension is common in all types of acute stroke, but whether prompt lowering of BP provides benefits without excessive risk has been a matter of longstanding controversy … until recently. The Intensive Blood Pressure Reduction in Acute Intracerebral Haemorrhage (ICH) Trial (INTERACT2) provides important new evidence of the efficacy and safety of early intensive BP lowering in ICH, where management of this condition has been largely supportive, and often nihilistic, in the absence of a proven treatment. The INTERACT2 results, together with other trial and observational data, has pushed guideline recommendations and clinical practice around the world towards more aggressive management of BP (towards a systolic target of b140 mmHg) rather than the conventional level of control (b180 mmHg). Further trial data also highlights the importance of early and smooth control of systolic BP, not just in the first 24 hours but over the subsequent several days after ICH. The effectiveness of early intensive BP lowering in routine clinical practice will depend on better understanding the barriers and facilitators of changing systems for delivering such care using streamlined protocols and quality improvement strategies. Planned extensions of INTERACT2 include studies of very early pre-hospital paramedical initiation of BP lowering therapy and multifaceted Health Systems Intervention strategies designed to reconfigure systems of care to enhance delivery of early BP lowering treatment across a range of health care settings. Effective implementation of complex interventions requires system changes in clinical practice. doi:10.1016/j.jns.2015.09.172
1599 WFN15-1856 Neuroimaging MT 9.2 - Cerebrovascular Imaging Brain imaging in patients with transient ischemic attack F. Purroy. Stroke Unit. Clinical Neurosciences Group, Hospital Universitari Arnau de Vilanova. IRBLleida, Lleida, Spain Since the new tissue definition of transient ischemic attack (TIA), diffusion weighted imaging (DWI) has become essential for the management of patients with transient neurological symptoms. Despite transient of symptoms up to one out of three patients had acute ischemic lesions. But, what is more important, classically defined TIA patients (duration of symptoms less than 24 hours) who have abnormalities on DWI have a higher risk of early recurrent ischemic events than those without such abnormalities. It has been demonstrated how the incorporation of neuroimaging data in the clinical prognostic scores, like ABCD2 score, improves its predictive power. Furthermore, not only the presence of acute ischemic lesions but also the pattern of distribution matters. Patients with scattered lesions due to large artery atherosclerosis have the highest risk of stroke recurrence. Moreover, perfusion imaging with perfusion MRI or CT perfusion may improve the detection of ischemic lesions. The combination of DWI and perfusion MRI can document the presence of a cerebral ischemic lesion in approximately half of all patients. Finally, other neuroimaging parameters different from DWI, such us
Abstracts / Journal of the Neurological Sciences 357 (2015) e457–e512
e465
the presence cerebral microbleeds, have emerged as novel predictors of stroke recurrence.
doi:10.1016/j.jns.2015.09.173
1600 WFN15-1794 Neurological Infections MT 12.2 - Parasitic and Fungal Disorders Neurocysticercosis A. Carpio. School of Medicine, University of Cuenca, Cuenca, Ecuador Neurocysticercosis (NC), the most common parasitic brain disease worldwide, is still a cause of unacceptable morbidity and mortality in endemic areas and is an emerging public health problem in high-income countries. Its clinical heterogeneity is related to localization, number and stage of evolution of the parasites, gender, age and intensity of the host brain inflammatory reaction.. In Inflammation is the main phenomenon responsible of symptomatology. Control of the inflammatory reaction in NCC is under debate today: it can surely reduce frequency of some complications, but it can also contribute to the poor clinical evolution of some patients. Acute symptomatic seizures are the most common symptom in patients with parenchymal parasites, but most do not evolve into epilepsy. Co-existence of cysticercus antibodies does not necessarily imply causation of epilepsy. Because of the high prevalence of each condition in developing countries, a causal as well as fortuitous relationship between the two pathologies might exist. NC diagnosis is based mainly on neuroimaging. New imaging techniques have improved detection of the scolex and visualization of cysts in the CNS. Immunological testing could be useful, particularly when imaging is equivocal. A study to assess the reliability, sensitivity and specificity of new set of diagnostic criteria is currently under way, which might allow early detection of, and differentiation between, parasites located in the parenchyma or in the extraparenchymal compartments. Based on disappearance of parasites, antihelminthic drugs as currently used are effective in approximately one third of patients with parenchymal viable cysts.
doi:10.1016/j.jns.2015.09.174
1601 WFN15-1873 Neurological Infections MT 12.2 - Parasitic and Fungal Disorders Trypanosomiasis M. Bentivoglio. Dept Neurological and Movement Sciences, University of Verona, Verona, Italy Nervous system infections caused by the flagellate protozoan trypanosomes include American trypanosomiasis or Chagas disease, caused by the intracellular Trypanosoma cruzi, transmitted by many species of triatomine bugs, and human African trypanosomiasis (HAT), also called sleeping sickness, caused by the extracellular Trypasonoma brucei, inoculated through bites of tsetse flies (genus Glossina). During its chronic phase T. cruzi infection attacks mainly the autonomic nervous system, with heart and gastrointestinal tract denervation. Chagas disease, which is highly invalidating, remains a public health issue in Latin America despite recent progress in vector control. In HAT, the first, haemolymphatic stage evolves into the second, meningoencephalitic stage, targeting the central nervous system when parasites cross the blood-brain barrier. HAT, which has two forms caused by T. brucei gambiense and rhodesiense, respectively, has a focal distribution in sub-Saharan Africa, mostly in resource-poor and politically unstable settings. Both forms of HAT