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Differentiating hemorrhagic infarct from parenchymal intracerebral hemorrhage can be difficult. The immediate and long-term management of the two conditions are different and hence the importance of accurate diagnosis. Using a series of intracerebral hemorrhage cases presented to our stroke unit, we aim to highlight the clues that may be helpful in distinguishing the two entities. The main clue to the presence of hemorrhagic infarct on computed tomography scan is the topographic distribution of the stroke. Additional imaging modalities such as computed tomography angiogram, perfusion, and magnetic resonance imaging may provide additional information in differentiating hemorrhagic infarct from primary hemorrhages.

Objective: Inflammation is increasingly viewed as a new therapeutic target in subacute stages of brain infarction. However, apart from causing secondary damage, inflammation could equally promote beneficial lesion remodeling and repair. Distinct subpopulations of monocytes/macrophages (MOs/MPs) may critically determine the outcome of lesion-associated inflammation. Methods: We addressed the role of bone marrow-derived MOs/MPs in 2 different mouse models of ischemic stroke using a combined cell-specific depletion, chemokine receptor knockout, bone marrow chimeric, and pharmacological approach. Results: Starting within 24 hours of stroke onset, immature Ly6chi monocytes infiltrated into the infarct border zone and differentiated into mature Ly6clo phagocytes within the lesion compartment. MO/MP infiltration was CCR2-dependent, whereas we did not obtain evidence for additional recruitment via CX3CR1. Depletion of circulating MOs/MPs or selective targeting of CCR2 in bone marrow-derived cells caused delayed clinical deterioration and hemorrhagic conversion of the infarctions. Bleeding frequently occurred around thin-walled, dilated neovessels in the infarct border zone and was accompanied by decreased expression of transforming growth factor (TGF)-β1 and collagen-4, along with diminished activation of Smad2. Injection of TGF-β1 into the lesion border zone greatly reduced infarct bleeding in MO/MP-depleted mice. Interpretation: Bone marrow-derived MOs/MPs recruited via CCR2 and acting via TGF-β1 are essential for maintaining integrity of the neurovascular unit following brain ischemia. Future therapies should be aimed at enhancing physiological repair functions of CCR2+ MOs/MPs rather than blocking their hematogenous recruitment. ANN NEUROL 2012;71:743–752

Isolated facio-lingual hypoesthesia and weakness is rare. We describe a case of isolated facio-lingual hypoesthesia and weakness after a hemorrhagic infarct localized at the contralateral operculum. A 66-year-old woman developed acute onset of facio-lingual hypoalgesia, hypoesthesia, and weakness, with no such symptoms being observed in other parts of the body. Brain magnetic resonance imaging showed a subacute hemorrhagic infarct in the right frontal operculum, which spread slightly to the right temporo-parietal operculum. 123 IMP-SPECT showed hypoperfusion in the right fronto-temporo-parietal operculum, as detected by MRI, without apparent diaschisis within the brain. Neuroimaging findings for our patient suggested the involvement of the primary somatosensory-motor cortices (S1 and M1) and the secondary somatosensory cortex (S2), which receive trigemino-thalamo-cortical pathways.

A 10-yr-old HbE/Beta thalassemia child who developed subacute to chronic occipitotemporal hemorrhagic infarct with smaller chronic infarct with gliotic changes in the left frontal periventricular white matter. Genetic tests showed that patient was positive for HbE and IVS1-5 mutation and was negative for thrombogenic mutations. Hemorrhagic infarct was confirmed by magnetic resonance imaging study. Antigenic levels of Protein C and Protein S were low. Based on these outcomes, it was concluded that Protein C and Protein S deficiency were the causative factor for developing hemmoragic infarct in the HbE/ Beta thalassemia patient.

Cortical venous thrombosis (CVT) is a common and frequently unrecognized type of stroke that affects approximately five people per million annually and accounts for 0.5-1% of all strokes. Exact incidence in India is yet to be documented. Puerperal CVT may account for the majority of CVT cases in India. Cerebral venous sinus thrombosis (CVST) usually affects young to middle aged groups. Outcome of CVST patients may vary from complete recovery to permanent neurological deficits, with varying presentation of the natural course of the disease. Factors related to poor outcome were papilledema, altered consciousness, coma, age older than 33 years, diagnostic delay >10 days, intracerebral hemorrhage, and involvement of the straight sinus. This case report is of thrombosis in the deep venous system of brain causing venous infarction of unilateral thalamus. There are very few cases reported all over the world with unilateral thalamic venous infarct. Prognosis of unilateral deep cerebral vein thrombosis is said to be better than that of bilateral thrombosis, if detected early and timely treated. Patient with a unilateral thrombosis may show complete recovery from his neurologic symptoms. Reports of reversible edema of the thalamus are well documented. In this case, patient is overall well preserved except that he continues to have recent memory impairment even after 4 weeks of discharge from hospital.

Study objective: This study investigated the relations between hemorrhagic infarction and occlusion, release, levels of glycemia, brain energy state, and lactate content after cerebrovascular occlusion. Design: Prospective, controlled laboratory investigation. Type of participants: One hundred six pentobarbital-anesthetized cats. Interventions: The middle cerebral artery was occluded with a Yasargil clip transorbitally either temporarily (0.5, four, and eight hours) or permanently. Normoglycemic and hyperglycemic animals were closely monitored for eight hours. Brain pathology was assessed after two weeks' survival or at the time of spontaneous animal death. Topographic brain metabolite studies were carried out after four hours of middle cerebral artery occlusion. Measurements and main results: Morphometric quantitation of cerebral hemorrhage and infarction and fluorometric determinations of blood and brain tissue, glucose, glycogen, lactate, adenosine triphosphate, and phosphocreatine from 16 topographic brain sites were carried out. Twenty-one of 82 (25.6%) animals evaluated neuropathologically showed hemorrhagic infarcts. Occluding the artery in hyperglycemic animals caused fivefold more frequent and 25-fold more extensive hemorrhage into infarcts than in normoglycemic animals. Temporary occlusion with clip release after four hours in hyperglycemic animals caused the most extensive hemorrhage into infarcts. Most hemorrhages into infarcts (81%) took place in animals that died within a few hours after they experienced ischemia and that showed infarction and marked edema of the entire middle cerebral artery territory. Linear regression analyses demonstrated a close relation between hemorrhage into infarcts and near-total energy depletion (adenosine triphosphate, less than 0.3 μM/g; phosphocreatine, less than 0.5 μM/g) in brain sites that showed extremely high tissue lactate concentrations (more than 30 μM/g). The biochemical changes that correlated with hemorrhage into infarcts were more marked than those with infarcts without hemorrhage. Conclusion: Hyperglycemia and restoration of blood flow to ischemic territories were strong risk factors for hemorrhagic infarct conversion. Concomitant tissue metabolic changes suggest that marked tissue energy depletion accompanied by acidosis damages brain vessels and renders them penetrable for edema fluid and, ultimately, red blood cell extravasation.

We examined the brains of 14 patients (four men and 10 women, mean age 68.9 years) who died from brain herniation after cardioembolic stroke with persistent occlusion of the internal carotid-middle cerebral arterial axis. Our examination showed hemorrhagic infarct in seven patients and pale infarct in the other seven, contradicting the commonly proposed pathophysiologic mechanism for the development of hemorrhagic infarct that the opening of previously occluded vessels makes an infarct hemorrhagic. Analysis of blood pressure after stroke revealed one or more surges of arterial hypertension or rapid rise of blood pressure in patients with hemorrhagic infarct without a reopening of the occluded artery. Such arterial hypertension was not always present in patients with pale infarct. Hemorrhage into an infarct with persisting occlusion of the proximal artery is assumed to occur when the involved blood vessels are exposed to the force of arterial blood pressure from the leptomeningeal collaterals. This occurs when arterial blood pressure rises after stroke in the presence of efficient leptomeningeal collaterals and before occlusion of these collaterals by a swollen cerebral hemisphere containing a large infarct.

There is growing evidence in support of ischemic stroke as a manifestation of COVID-19 infection. However, hemorrhagic transformation of ischemic stroke is rare. We present two cases of hemorrhagic infarction as presenting features in COVID-19 patients who did not have traditional cardiovascular risk factors for ischemic or hemorrhagic stroke. While the hemorrhagic infarct was from a large artery in one of the patients, the other patient had a small artery related hemorrhagic infarct. We highlighted the possible underlining mechanisms from the literature and the implication of hemorrhagic infarct for routine anticoagulant therapy in patients with COVID −19 related ischemic stroke.

Objectives The aim of the study is to assess the role of ultrafast (UF) magnetic resonance (MR) sequences in stroke imaging. Material and Methods We prospectively studied 85 patients having clinical suspicion of stroke referred for MR imaging (MRI) during August 2016 to July 2018. These patients were subjected to both conventional and UF MRI sequences. The patients were divided into six categories based on the pathologies encountered. Further subclassification was done based on the size of the lesions as ≤10 mm and >10 mm as seen separately in both UF and conventional MR sequences. The number and visibility of these lesions on conventional and UF MRI were compared. The image quality of all the subjects was also compared based on a scale categorized into excellent, satisfactory, and poor. The findings on conventional and UF imaging sequences were correlated with the final clinical diagnosis arrived at the time of discharge. Results In our study comprising 85 patients, 57 showed pathologies. The patients showing pathologies were assigned into the six categories as acute infarct (34 cases), acute hemorrhagic infarct (six cases), chronic infarct (17 cases), chronic hemorrhagic infarct (four cases), subacute infarct (three cases), and chronic hemorrhage (one case). The number of lesions seen on conventional and UF sequences were the same although there was a slight decrease in the size of the lesions on UF sequences as compared with conventional counterparts. The image quality using UF sequences was better in motion prone patients while conventional imaging showed better image quality in cooperative patients. Conclusion In motion prone patients, UF sequences are a suitable alternative for conventional sequences as they help in arriving at the diagnosis in lesser time, with reasonably good image quality, and without motion artifacts. In cooperative stroke patients, it is better to use conventional MR sequences as the image quality is better.

Objectives In this study, we presented neuroradiologic findings and diagnoses of neurologic complications in a series of heart transplant recipients. Materials and methods A retrospective review was conducted at Baskent University Hospital. We searched the hospital and radiology databases and identified 109 heart transplant recipients. Thirty-one of these recipients had neuroradiologic evaluations secondary to presentation of neurologic symptoms after heart transplant, with 18 patients evaluated with computed tomography and 22 patients evaluated with magnetic resonance imaging (overlap of imaging-defined groups occurred in 9 recipients). Computed tomography and magnetic resonance imaging studies were retrieved from the Picture Archiving and Communication System, with each type of imaging retrospectively evaluated on consensus by 2 radiologists. Results Radiopathologic findings related to symptoms were detected in 12 of the 31 study patients. The most common abnormality was posterior reversible leukoencephalopathy syndrome (5 patients, 4.6%). The other abnormalities were ischemic stroke (3 patients, 2.8%), hemorrhagic stroke (1 patient, 0.9%), intracranial abscess (2 patients, 1.8%), and intracranial dissemination of sinusoidal fungal infection and related hemorrhagic infarct (1 patient, 0.9%). The other 19 heart transplant recipients who underwent computed tomography and/or magnetic resonance imaging for neurologic complaints showed no neuroradiologic findings related to neurologic symptoms. Conclusions Posterior reversible leukoencephalopathy syndrome and ischemic stroke were the most common neurologic complications in our heart transplant recipients. The other complications were hemorrhagic stroke, intracranial abscess, and intracranial dissemination of sinusoidal fungal infection. Neurologic complications are common in heart transplant recipients and should be identified promptly for early treatment. For the recognition of these complications, computed tomography should be performed for initial evaluation to rule out edema or hemorrhage. However, in the presence of serious neurologic symptoms that cannot be explained by computed tomography, magnetic resonance imaging should be indicated.

Efficacy and safety of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) due to intracranial artery dissection (IAD) are currently not established. We aimed to present a single-center experience on IAD-related AIS treated by IVT. We selected all consecutive patients with IAD-related AIS treated by IVT from a prospectively constructed single-center acute stroke registry from 2003 to 2017. We reviewed demographical, clinical and neuroimaging data and recorded hemorrhagic complications, mortality within 7 days and modified Rankin Scale at 3-months. Out of 181 AISs related to cervicocephalic dissections, 10 (5.5%) were due to IAD and five of these patients received IVT. Among these five patients, median age was 62 years; hypertension and dyslipidemia were the most frequent vascular risk factors. IAD locations were distal internal carotid artery, middle cerebral artery (M1), anterior cerebral artery (A2), and, in two cases, the basilar artery. All anterior circulation IADs were occlusive or subocclusive, while the two basilar artery IADs caused arterial stenosis. After IVT, there were no subarachnoid or symptomatic intracranial hemorrhages. One patient had an asymptomatic hemorrhagic infarct type 1. Two patients died within 7 days from ischemic mass effect. The other three patients had favorable clinical outcomes at 3-months. In this small single-center case series of IAD-related AIS, thrombolysis seemed relatively safe. However, IVT efficacy and the likelihood of arterial recanalization are still uncertain in this context. Further studies are needed to assess the safety and efficacy of IVT in these patients.

Background: Hemorrhagic transformation (HT) is a frequent complication of acute ischemic stroke (AIS). Red blood cell distribution width (RDW) is a cost-effective parameter associated with incidence and prognosis of cerebrovascular diseases. The purpose of this study was to assess whether RDW is associated with HT in AIS patients. Methods: AIS patients within 24 h from stroke onset between January 1, 2014, and December 31, 2018, were consecutively enrolled. Blood samples were collected. The primary outcome was HT, which was diagnosed by follow-up brain image and classified into hemorrhagic infarct (HI) and parenchymal hematoma (PH). Multivariate logistic regression analysis was performed to determine the relationship between RDW and HT as well as its subtypes. Potential effect modifier was identified by stratified logistic regression analysis. Results: Among the included 1383 patients, 220 (15.9%) developed HT (HI in 103 and PH in 117). Elevated RDW levels were associated with an increased risk of HT when 2 extreme tertiles were compared (OR 1.60, 95% CI 1.04–2.44, p = 0.031). The risk of HT increased stepwise across RDW tertiles (p for trend = 0.042). RDW significantly correlated with HI rather than PH. The association between RDW and HT could be modified by reperfusion therapy (p for interaction = 0.010), with no significant association between RDW and HT among patients underwent reperfusion therapy. Conclusions: Elevated RDW level was related to increased risk of HT among AIS patients without reperfusion therapy.

BackgroundMobile stroke units (MSUs) performance dependability and diagnostic yield of 16-slice, ultra-fast CT with auto-injection angiography (CTA) of the aortic arch/neck/circle of Willis has not been previously reported.MethodsWe performed a prospective observational study of the first-of-its kind MSU equipped with high resolution, 16-slice CT with multiphasic CTA. Field CT/CTA was performed on all suspected stroke patients regardless of symptom severity or resolution. Performance dependability, efficiency and diagnostic yield over 365 days was quantified.Results1031 MSU emergency activations occurred; of these, 629 (61%) were disregarded with unrelated diagnoses, and 402 patients transported: 245 (61%) ischemic or hemorrhagic stroke, 17 (4%) transient ischemic attack, 140 (35%) other neurologic emergencies. Total time from non-contrast CT/CTA start to images ready for viewing was 4.0 (IQR 3.5–4.5) min. Hemorrhagic stroke totaled 24 (10%): aneurysmal subarachnoid hemorrhage 3, hemorrhagic infarct 1, and 20 intraparenchymal hemorrhages (median intracerebral hemorrhage score was 2 (IQR 1–3), 4 (20%) spot sign positive). In 221 patients with ischemic stroke, 73 (33%) received alteplase with 31.5% treated within 60 min of onset. CTA revealed large vessel occlusion in 66 patients (30%) of which 9 (14%) were extracranial; 27 (41%) underwent thrombectomy with onset to puncture time averaging 141±90 min (median 112 (IQR 90–139) min) with full emergency department (ED) bypass. No imaging needed to be repeated for image quality; all patients were triaged correctly with no inter-hospital transfer required.ConclusionsMSU use of advanced imaging including multiphasic head/neck CTA is feasible, offers high LVO yield and enables full ED bypass.

BACKGROUND AND PURPOSE: Although most cervical dissections are managed medically, emergent endovascular treatment may become necessary in the presence of intracranial large-vessel occlusions, flow-limiting and long-segment dissections with impending occlusion, and/or hypoperfusion-related ischemia at risk of infarction. We investigated the role of emergent endovascular stenting of long-segment carotid dissections in the acute ischemic stroke setting. MATERIALS AND METHODS: We retrospectively studied long-segment carotid dissections requiring stent reconstruction with multiple tandem stents (≥3 stents) and presenting with acute (70% flow limiting stenosis and involved the distal cervical ICA with a minimum length of 3.5 cm. Carotid stent reconstruction was successful in all patients with no residual stenosis or flow limitation. Nine patients (60%) harbored intracranial occlusions, and 6 patients (40%) required intra-arterial thrombolysis/thrombectomy, achieving 100% TICI 2b–3 reperfusion. Two procedural complications were limited to thromboembolic infarcts from in-stent thrombus and asymptomatic hemorrhagic infarct transformation (7% morbidity, 0% mortality). Angiographic and ultrasound follow-up confirmed normal carotid caliber and stent patency, with 2 cases of

A 51-year-old woman with history of hypertension presented with left-sided weakness and diplopia. Imaging revealed a large hemorrhagic infarct involving the right thalamus and rostral midbrain with intraventricular extension (figure). Neuro-ophthalmic examination demonstrated bilateral upgaze palsy with limitation of infraduction on the right (video 1), overcome with a doll's head maneuver (video 2). Bilateral lid retraction was present with markedly reduced convergence along with convergence-retraction nystagmus. Vertical one-and-a half syndrome is an uncommon presentation resulting from a unilateral thalamomesencephalic stroke with involvement of the rostral interstitial nucleus of the medial longitudinal fasciculus and posterior commissure1 and was accompanied here by dorsal midbrain syndrome.

Background A prospective, observational study was done at a tertiary care hospital in Western Maharashtra to describe the etiologies, clinical features, diagnosis and prognosis of cerebral venous sinus thrombosis in an Indian population. Methods 54 patients with clinical and MRI features suggestive of cerebral venous sinus thrombosis (CVST), were studied with detailed clinical evaluation and pro-thrombotic work up. All were followed up monthly for 6 months, to assess the response to therapy and clinical outcomes. Results The mean age of presentation was 35 years. Headache was the most common presenting symptom (94%) and hemi paresis (22%) was the most common neurological sign. The most common sinus involved was transverse sinus in 77% of cases. In the unprovoked CVST subset (n = 29), elevated factor VIII (72%) and protein C deficiency (24%) were the common prothrombotic states identified. In the provoked CVST subset (n = 18), puerperium (44%) and para-infectious (22%) accounted for majority cases. Idiopathic CVST accounted for 13% (7/54) in this study. A Modified Rankin Scale (MRS) of 0–1 was achieved in 96% of patients at the end of 6 months follow up with no mortality in this study. Conclusion CVST is an important yet under recognized cause of intracranial hypertension and stroke in young. Clinical presentation is extremely varied and a high index of suspicion is needed. Magnetic Resonance Imaging (MRI) brain with Magnetic Resonance Venography (MRV) is the current diagnostic modality of choice. Elevated factor VIII and puerperium are the common etiologies in an Indian population. Management with anticoagulants is safe and has excellent clinical outcomes.

Background Cerebral venous thrombosis is a rare cause of stroke that poses diagnostic, therapeutic, and prognostic challenges. Mainstay treatment is systemic anticoagulation, but endovascular treatment is increasingly advocated. Our objectives were to describe the epidemiology, treatment, and prognosis of 152 patients with cerebral venous thrombosis. Methods and Results This was a retrospective study of consecutive cerebral venous thrombosis cases from 2006 to 2013 at a comprehensive stroke center through hospital discharge. Predictors of full recovery (modified Rankin Scale scores 0–1) were analyzed with multiple logistic regression and presented as adjusted odds ratios ( AORs ) with 95% confidence intervals ( CIs ). The population was young (average age: 42 years), majority female (69%), and commonly presenting with cerebral edema (63%), and 72% were transferred in. All patients received systemic anticoagulation; 49% (n=73) required endovascular treatment. Reasons for requiring endovascular treatment included cerebral edema, herniation, or hemorrhagic infarct (n=38); neurologic decline (n=17); rethrombosis, persistent occlusion, or clot propagation (n=10); extensive clot burden (n=7); and persistent headache despite anticoagulation (n=1). There were 7 (10%) procedural complications. Recanalization was successful (61%), partial (30%), and unsuccessful (9%). Overall, 60% fully recovered. Positive predictors of full recovery included hormonal etiology, particularly for patients who were transferred in ( AOR : 7.06 [95% CI, 2.27–21.96], interaction P =0.03) and who had migraine history ( AOR : 4.87 [95% CI, 1.01–23.50], P =0.05), whereas negative predictors of full recovery were cerebral edema ( AOR : 0.11 [95% CI, 0.04–0.34], P AOR : 0.28 [95% CI, 0.09–0.96], P =0.04). Conclusions As one of the largest cohort studies, our findings suggest that cerebral edema, history of migraine, and hormonal etiology were prognostic and that endovascular treatment might be a safe and effective treatment for cerebral venous thrombosis when conventional management is inadequate.

Background and Purpose— Secondary intracerebral hemorrhage (sICH) is a potentially serious complication of ischemic stroke, in particular under concomitant oral anticoagulation. Previous studies in murine stroke models defined a novel vascular repair function of hematogenous monocytes/macrophages (MO/MP), which proved essential for the prevention of oral anticoagulation–associated sICH. Here, we addressed the question whether hyperglycemia as a clinically relevant prohemorrhagic risk factor and peroxisome proliferator-activated receptor gamma (PPARγ) activation affect MO/MP differentiation and the risk of sICH after ischemic stroke. Methods— Oral anticoagulation–associated sICH was induced by phenprocoumon feeding to mice undergoing transient middle cerebral artery occlusion. Hyperglycemia was induced by streptozotocin treatment. The role of PPARγ-dependent MO/MP differentiation was addressed in mice with myeloid cell–specific PPARγ-knockout (LysM-PPARγ(KO)). Pharmacological PPARγ activation via pioglitazone was tested as a treatment option. Results— Hyperglycemic mice and normoglycemic LysM-PPARγ(KO) mice exhibited abnormal proinflammatory skewing of their hematogenous MO/MP response and abnormal vascular remodeling in the infarct border zone, leading to an increased rate of oral anticoagulation–associated sICH. Pharmacological PPAR γ activation in hyperglycemic mice corrected the inflammatory response toward an anti-inflammatory profile, stabilized neovessels in the infarct border zone, and reduced the rate of sICH. This preventive effect was dependent on the presence of macrophages, but independent from effects on blood glucose levels. Conclusions— Hyperglycemia and macrophage-specific PPARγ activation exert opposing effects on MO/MP polarization in ischemic stroke lesions and, thereby, critically determine the risk of hemorrhagic infarct transformation.

OBJECTIVES: To determine raised serum hsCRP levels, an established risk marker in stroke patients and also to study the co relation between raised serum uric acid and hsCRP levels in ischemic and hemorrhagic stroke. MATERIALS AND METHODS: This was a cross sectional study of 200 patients presenting with a history of focal neurological deficit of acute onset in the form of hemiparesis, hemiplegia having evidence of presence of ischemic or hemorrhagic infarct in CT scan of brain. In all patients hsCRP levels were measured within 48hours of presentation. RESULTS: Most of the patients (65%) were in the age group of more than 50 years. Left-sided hemiparesis with altered sensorium and UMN facial palsy was the most common presenting symptom. hsCRP levels were found to be increased in hemorrhagic stroke patients than with ischemic stroke, this difference was found to be statistically significant (p < 0.001). CONCLUSION: From this study we concluded that hsCRP level is increased in cases of stroke - ischemic as well as hemorrhagic, but more in hemorrhagic stroke suggesting an inflammatory response in acute stroke. Furthermore, the increased levels correlated with larger bleed and infarct size, severe neurological deficit and worse outcome.

Objective: To determine if an acute loading dose of clopidogrel is safe in acute ischemic stroke (AIS) patients with chronic intracerebral hemorrhage (ICH). Background: Clopidogrel loading is a promising therapy for AIS patients not eligible for tissue plasminogen activator (tPA) who are at risk for progressive stroke. Previous ICH is a risk factor for developing a new ICH. However, the acute risk of these events in this population after loading with clopidogrel has not been studied. Methods: We examined 1,011 AIS patients presenting to our center from 06/07/07-07/31/13. Only those loaded with at least 300mg of clopidogrel (with or without aspirin) within 6 hours of admission were analyzed. We compared new onset hemorrhagic complications in patients with and without chronic ICH, defined as areas of parenchymal hypodensity on gradient recall echo (GRE) sequencing on MRI. Repeat CT or MRI during admission was evaluated by a vascular neurologist for evidence of new ICH, hemorrhagic infarct using ECASS II criteria, or new ischemic infarct. Results: Of 365 AIS patients loaded with clopidogrel, 67 had chronic ICH on GRE. Patients with chronic ICH were more likely to be African American (80.0% vs. 65.9%, p=0.028) and male (69.2% vs. 50.9%, p=0.008). These patients were more likely to have existing comorbidities: history of stroke (67.7% vs 37.5%, p 2 on discharge, p=0.889), or unfavorable discharge disposition (defined as disposition other than home or inpatient rehabilitation, p=0.166). Conclusion: The presence of chronic ICH on GRE did not increase the risk of new ICH, hemorrhagic infarct, ischemic event, or neurologic deterioration after administration of an acute loading dose of clopidogrel for AIS.

Background: Stroke a major public health problem, its management remains a challenge for the medical professionals. We investigated the clinical, simple biological and tomographic determinants of outcome in patients suffering of ischemic stroke. Materials and methods: This prospective study was conducted at Kinshasa university hospital from January 2011 to June 2014. A total of 104 consecutive patients with first-ever ischemic stroke confirmed by computed tomography examination were enrolled for the study. The parameters of interest were clinical, routine biochemical and radiological data within the 3 first days of symptom onset. Logistic regression was used to identify independent determinants of mortality risk. Results: The average age of patients was 62 ± 14 years old with 68% of male. Among the 22 patients (21%) who died, in univariate analysis, factors associated with lethality were the Glasgow score 40 mm/1h, higher leukocytosis > 10.000 elements/mm3 and non-lacunar brain infarct. On multiple logistic regression analysis, higher elevated erythrocyte sedimentation rate (OR 1.8; 95% CI 1.22 to 89.35; p=0.032), lesion located in infra-tentorial area (OR 4.7; 95% CI 1.30 to 16.38; p=0.017) and hemorrhagic infarct (OR 10.6; 95% CI 2.21 to 77.89; p=0.005) were essentially independent determinants of ischemic stroke mortality. Conclusion: The study seems to determine factors associated with mortality in patients suffering from cerebral infarction. Glasgow score and routine biomarkers may be useful in low setting area to assess mortality in ischemic stroke patient.

Background and Purpose— The purpose of this study was to determine whether leukoaraiosis (LA) predicts hemorrhagic transformation and poor outcome in patients with acute ischemic stroke treated by mechanical thrombectomy. Methods— We retrospectively analyzed patients with anterior circulation stroke treated with Merci devices and identified LA in the deep white matter (DWM) and periventricular white matter on the preintervention MR images. We dichotomized patients into those with moderate or severe LA in the DWM versus those without. Hemorrhage rates and outcomes were evaluated between 2 groups. We analyzed the association of moderate or severe LA with hemorrhagic transformation and poor outcome. Results— Twenty-six of 105 patients had moderate or severe LA in the DWM. Patients with moderate or severe LA in the DWM were older, had more severe neurological deficits and worse outcome, had higher rates of hemorrhagic transformation and parenchymal hematoma, but had equivalent rates of hemorrhagic infarct and subarachnoid hemorrhage when compared with those without. Patients with only periventricular LA did not have a higher rate of parenchymal hematoma. Moderate or severe LA in the DWM was an independent predictor of hemorrhagic transformation (OR, 3.4; P =0.019) and parenchymal hematoma (OR, 6.3; P =0.005). Patients with parenchymal hematoma were less often independent (modified Rankin Scale ≤2, 3.8% versus 32.5%; P =0.003) and had greater in-hospital mortality (50% versus 10.4%; P Conclusions— Moderate or severe LA in the DWM increases the risk of parenchymal hematoma after Merci thrombectomy for patients with acute stroke. These findings require validation in a larger prospective study.

The Penumbra system is a newly approved mechanical device for the treatment of acute stroke designed for better and faster recanalization. We describe our initial experience with the use of this device. We studied 27 consecutive patients with acute ischemic strokes due to arterial occlusions presenting at our center from January to October 2009. The primary outcome was the degree of recanalization measured by thrombolysis in myocardial infarction (TIMI grade 2/3) at the end of the procedure. Secondary end points were the proportion of patients who achieved a modified Rankin scale (mRS) ≤2 at 3 months, all-cause mortality and intracerebral hemorrhage (ICH) on non contrast computed tomography at 24 h. Procedural complications were also recorded. Of 27 patients (13 male, mean age 61 years) in the study, 22 (81%) patients had anterior circulation strokes and five (18%) had posterior circulation strokes. Twenty-three (85%) patients achieved TIMI grade 2/3 recanalization at completion of the procedure. Excluding five patients who needed use of a second device, the Penumbra system achieved TIMI grade 2/3 recanalization in 67% of patients. Thirteen (48%) patients had mRS ≤2 at 3-month follow-up. Procedural and post-procedural complications included vasospasm (3.7%), distal emboli (48.1%), and ICH (33.3%). The distribution of ICH is as follows: hemorrhagic infarct type 1 (25.9%), parenchymal hemorrhage type 1 (3.7%), and parenchymal hemorrhage type 2 (3.7%). All-cause mortality was 19%. High recanalization rates and good clinical outcomes are achievable with the Penumbra system. Complication rates are comparable to a previously published literature.

OBJECTIVE AND IMPORTANCE: Cerebral venous and dural sinus thrombosis is a rare cause of stroke. Although morbidity and mortality have greatly decreased in recent years as a result of early diagnosis and timely medical treatment, when coma occurs the prognosis remains poor. We evaluated whether emergent decompressive craniectomy has a role in the treatment of patients with brain herniation from dural sinus thrombosis and hemorrhagic infarct. CLINICAL PRESENTATION: Three patients developed large hemorrhagic infarct with coma and bilaterally fixed and dilated pupils resulting from aseptic dural sinus thrombosis. INTERVENTION: Two patients underwent emergent surgical decompression as soon as brain herniation developed, and these patients had complete functional recovery. One underwent delayed surgical decompression and remained severely disabled. CONCLUSION: Our results provide preliminary evidence that emergent decompressive craniectomy is effective in patients with brain herniation from dural sinus thrombosis, provided that the clinical onset is recent. We therefore recommend consideration of this aggressive surgical technique for such patients, who may survive with good outcomes.

Purpose. Perinatal stroke is the most frequent cause of congenital hemiplegia. The MR imaging features of cerebral infarction in full-term newborns will be reviewed and the underlying etiologies discussed. Patients and methods. Retrospective study (1999-2005) including 15 newborn infants without history of fetal distress with early seizures (before day 7) with ischemic or hemorrhagic infarct on MR. All MR examinations were reviewed by consensus (MBD, CHA) using a checklist and results were correlated with findings at clinical follow-up (mean follow-up of 1 year). Results. MR showed ischemic strokes in 10 infants (5 left, 4 right, 1 bilateral) in the middle (n=9) or anterior (n=1) cerebral artery distribution or with extensive bilateral distribution. The cortex and subcortical regions were involved in all cases with ipsilateral basal ganglia/internal capsule extension in 4 cases. The imaging features were related to the timing of the MR examination: within 5 days (n=4): cortical effacement on T1W and T2W images, increased signal on DWI with reduced signal on ADC; between 7-14 days (n=6): T1W hyperintense and T2W hypointense cortex. Five infants had unifocal (3/5) or multifocal (2/5) hemorrhagic infacrtion. Of 13 patients followed-up from 3 months to 3 years (1 lost to follow-up, 1 deceased), 11 had no clinical deficits, 1 had hemiparesis, and 1 had asymmetrical muscle tone. The latter 2 infants had involvement of the posterior limb internal capsule, with basal ganglia and hemispheric involvement. In the literature, this association of lesions is considered predictive of hemiplegia and a high rate of sequelae is reported following neonatal stroke: 50-75% with motor deficit and/or seizure disorder. The 4 infacts with hemorrhagic infarction followed-up for 14 months to 5 years had a globally favorable neurological outcome. Conclusion. Cerebral infacrtion in full-term newborns without associated risk factor is variable and should be recognized. Early MR, before day 2, with diffusion-weighted sequences, allows diagnosis but follow-up MR after day 7 is necessary to better depict the extent of permanent lesions. The presence of hemorrhage is not a predictive factor of poor neurological outcome.

Invasive surgery brings with it a unique set of post-surgical risks that are directly dependent on various factors including the specific surgical approach used, pre-existing comorbidities and features such as gender and age. Pulmonary thromboembolism is one of the most feared complications following surgery, and diagnosis and treatment of this entity is a challenging task for the clinician. Here we describe a case of massive pulmonary thromboembolism and associated coronary artery thromboemboli status post spinal fusion surgery in a 68 year-old man with an undetected patent foramen ovale (PFO). Although the decedent was managed clinically with proper deep venous thrombosis prophylaxis protocols and physical rehabilitation, he went into cardiorespiratory arrest after experiencing acute oxygen desaturation and newly detected right bundle branch block. PFO can be incidentally found in 25% of the adult population. Several clinical syndromes including stroke, migraine headaches and obstructive sleep apnea have been associated in patients with PFO, the last two from which the decedent suffered. The pathology of this unique case of massive pulmonary thromboembolism resulting in coronary artery thromboemboli in the setting of an undetected PFO is discussed. The discovery of PFO in patients prior to surgery, if detected early, may improve post-surgical outcomes. Figure 1. Massive pulmonary artery thromboembolism in situ, gross examination. Figure 1. Massive pulmonary artery thromboembolism in situ, gross examination. Figure 2. Histology, hematoxylin and eosin. A. Pulmonary thromboembolus at the bifurcation of the pulmonary arteries and pulmonary trunk. B. Hemorrhagic infarct and thromboemboli in varying stages of organization, right lower lobe, lung. C. Cross section of the proximal left anterior descending coronary artery with thromboembolus. D. Cross section of the posterior descending coronary artery with thromboembolus. Figure 2. Histology, hematoxylin and eosin. A. Pulmonary thromboembolus at the bifurcation of the pulmonary arteries and pulmonary trunk. B. Hemorrhagic infarct and thromboemboli in varying stages of organization, right lower lobe, lung. C. Cross section of the proximal left anterior descending coronary artery with thromboembolus. D. Cross section of the posterior descending coronary artery with thromboembolus. Figure 3. Patent foramen ovale, gross examination. Figure 3. Patent foramen ovale, gross examination. Disclosures No relevant conflicts of interest to declare.

Background: Cerebral venous sinus thrombosis (CVST) is a rare form of stroke seen in young and middle aged group, especially in women due to thrombus of dural venous sinuses and can cause acute neurological deterioration with increased morbidity and mortality if not diagnosed in early stage. Neurological deficit occurs due to focal or diffuse cerebral edema and venous non-hemorrhagic or hemorrhagic infarct. Aim and Objectives: To assess/evaluate the role of Magnetic Resonance Imaging (MRI) and Magnetic Resonance Venography (MRV) as an imaging modality for early diagnosis of CVST and to study patterns of venous thrombosis, in detecting changes in brain parenchyma and residual effects of CVST using MRI. Materials and Methods: Retrospective descriptive analysis of 40 patients of CVST diagnosed on MRI brain and MRV was done. Results: 29/40 (72.5%) were males and 11/40 (27.5%) were females. Most of the patients were in the age group of 21-40 years (23/40-57.5%). Most of the patients 16/40 (40%) presented within 7 days. No definite cause of CVST was found in 24 (60%) patients in spite of detailed history. In 36/40 (90%) of cases major sinuses were involved, deep venous system were involved in 7/40 (17.5%) cases, superficial cortical vein was involved in 1/40 (2.5%) cases. Analysis of stage of thrombus (acute, subacute, chronic) was done based on its appearance on T1 and T2WI. 31/40 (77.5%) patients showed complete absence of flow on MRV, while 9/40 (22.5%) cases showed partial flow on MR venogram. Brain parenchyma was normal in 20/40 (50%) patients while 6/40 (15%) cases had non-hemorrhagic infarct and 14/40 (35%) patients presented with hemorrhagic infarct. Conclusion: Our study concluded that MRI brain with MRV is sensitive in diagnosing both direct signs (evidence of thrombus inside the affected veins) and indirect signs (parenchymal changes) of CVST and their follow up.

Despite an increased risk of stroke in pregnancy and puerperium, the overall incidence of the condition in this population is low. Therefore, there is limited data pertaining to these patients particularly from Asian countries. Our objective was to describe the risk factors and outcomes of 110 pregnancy-related ischemic strokes from 5 Asian countries.Data were collected by retrospective chart review in most cases and prospectively in the rest. Inclusion criteria for this subanalysis were women, pregnant or within 1-month postpartum, presenting to the study center with acute ischemic stroke (arterial or venous) confirmed by neuroimaging. Intracranial hemorrhages other than the ones associated with cerebral venous thrombosis or hemorrhagic infarct were excluded. Risk factors were diagnosed based on already published criteria. Outcomes were measured using modified Rankin score. Statistical analysis was done using Statistical Package for Social Sciences version 19.0.In all, 110 women with mean age of 27.94 years presented with pregnancy-related ischemic strokes; 58.2% of the strokes occurred postpartum and 49.1% were secondary to cerebral venous thrombosis. Venous strokes were significantly more likely to occur postpartum compared with arterial strokes (P=.01), to have abnormal "hypercoagulable panel result on admission" (P.001), less likely to have traditional stroke risk factors (P.001), to have hemorrhagic conversion of stroke (P.001), and to have lesser stroke severity and better functional outcome at 3 months (P.001 for each).Cerebral venous thrombosis is a significant contributor to pregnancy-related strokes in Asian women. Both traditional and pregnancy-specific risk factors should be addressed to control ischemic stroke risk in these women.

We investigated 17 patients with 26 cerebellar hemorrhagic infarcts for their vascular anatomy, stroke mechanisms, and clinical course.Sixteen infarcts involved the superior cerebellar artery, nine the posterior inferior cerebellar artery, and one the anterior inferior cerebellar artery territories. The infarcts involved the full territory of the supplying arteries in 19 of 26 infarcts (73%). Sixteen of 17 patients were stable or improving when the hemorrhagic infarction was detected. All but one patient had an imaging study at the time of presentation that was negative for blood; hemorrhagic infarction was detected on routine serial scans performed during the first 15 days. Nine of the 17 patients were on anticoagulants when the cerebellar hemorrhagic infarct was detected; anticoagulation was maintained in eight of them with no clinical worsening. The stroke mechanism in all patients was considered embolic from cardiac and intraarterial sources. The causes, imaging findings, and consequences of hemorrhagic infarcts in the posterior circulation are similar to those in the anterior circulation. NEUROLOGY 1996;46: 346-349

Background: It is a well-known fact that very few patients of stroke arrive at the hospital within the window period of thrombolysis. Even among those who do, not all receive thrombolytic therapy. Objective: The objectives of this study were to determine the proportion of early arrival ischemic strokes (within 6 h of stroke onset) in our hospital and to evaluate the causes of nonadministration of intravenous and/or intraarterial thrombolysis in them. Materials and Methods: Data of all early arrival acute stroke patients between January 2010 and January 2015 were included. Factors determining nonadministration of intravenous and/or intraarterial thrombolysis in early arrival strokes were analyzed. Results: Out of 2,593 stroke patients, only 145 (5.6%) patients presented within 6 h of stroke onset and among them 118 (81.4%) patients had ischemic stroke and 27 (18.6%) patients had hemorrhagic stroke. A total of 89/118 (75.4%) patients were thrombolyzed. The reasons for nonadministration of thrombolysis in the remaining 29 patients were analyzed, which included unavoidable factors in 8/29 patients [massive infarct (N = 4), hemorrhagic infarct (N = 1), gastrointestinal bleed (N = 1), oral anticoagulant usage with prolonged international normalized ratio (INR) (N = 1), and recent cataract surgery (N = 1)]. Avoidable factors were found for 21/29 patients, include nonaffordability (N = 7), fear of bleed (N = 4), rapidly improving symptoms (N = 4), mild stroke (N = 2), delayed neurologist referral within the hospital (N = 2), and logistic difficulty in organizing endovascular treatment (N = 2). Conclusion: One-fourth of early ischemic stroke patients in our study were not thrombolyzed even though they arrived within the window period. The majority of the reasons for nonadministration of thrombolysis were potentially preventable, such as nonaffordability, intrahospital delay, and nonavailability of newer endovascular interventions.

Computed tomography (CT) was performed on an eleven-year-old dog four days after an acute onset of seizures and neurologic deficits. A ring-enhancing, intra-axial lesion associated with edema, falcial deviation and non-uniform ventricular compression was identified in the left frontal lobe. An area of ill-defined hyperdensity, compatible with hemorrhage, was noted on corresponding CT images prior to contrast enhancement. At post-mortem examination, a focal, hemorrhagic infarct, characterized by liquif ication necrosis, marked gliosis and neovascularization, was found. The etiology of the infarction could not be identified. The CT findings, however, were similar to those seen in humans with cerebral infarction due to embolic occlusion and subsequent hemorrhage. These findings and the pathophysi-ologic mechanisms behind them are discussed.

The management and outcome of cerebral venous thrombosis (CVT) may be different from that of arterial ischemic stroke (AIS). Clinically differentiating the 2 diseases on clinical grounds may be difficult. The main objective of this study was to identify predictors differentiating CVT from AIS in a large cohort of young Asian women, based on risk factors and investigations. Twelve centers in 8 Asian countries participated. Women aged 15-45 years were included if they had a diagnosis of first-ever symptomatic AIS or CVT confirmed by brain computed tomography scan or magnetic resonance imaging/magnetic resonance venography. Patients with head trauma, cerebral contusions, intracranial hemorrhage, and subarachnoid or subdural hemorrhage were excluded. Data, including demographic data, risk factor assessment, neuroimaging studies, blood tests, and cardiac studies, were collected by retrospective and then prospective chart review between January 2001 and July 2008. Outcome was based on the modified Rankin Scale (mRS) score at admission, discharge, and latest follow-up. A total of 958 patients (204 with CVT and 754 with AIS) were included in the study. Age under 36 years, anemia, pregnancy or postpartum state, and presence of hemorrhagic infarcts on computed tomography scan or magnetic resonance imaging were significant predictors of CVT on univariate analysis. Age over 36 years, diabetes, hypertension, dyslipidemia, recent myocardial infarction, electrocardiogram abnormalities, and blood glucose level >150 mg/dL were strong predictors of AIS. On multivariate analysis, postpartum state and hemorrhagic infarct were the strongest predictors of CVT (P < .001). Mortality was comparable in the 2 patient groups. Prognosis was significantly better for patients with CVT than for those with AIS (mRS score 0-2, 74% v 46%; P < .001). There was no difference in outcome between patients with obstetric and nonobstetric CVT. Our data indicate that in young Asian women, predictors of CVT differ from those for AIS. These findings could be useful in the early identification and diagnosis of patients with CVT.

Thrombolysis trials have recruited few patients aged ≥80 years, which has led to uncertainty about the likely risk-to-benefit profile in the elderly. Leukoaraiosis (LA) has been associated with hemorrhagic transformation (HT) and increases with advanced age. We tested whether there were any independent associations between age, LA and HT. Consecutive patients treated with intravenous (IV) tissue plasminogen activator (tPA) were identified from a prospective database. LA on baseline CT scans was assessed by two independent raters using the modified Van Swieten Score (mVSS) (maximum score 8, severe >4). HT was assessed on routine 24 hour to 48 hour CT /MRI scans using the European Cooperative Acute Stroke Study criteria for hemorrhagic infarct (HI) or parenchymal hematoma (PH) and judged symptomatic by the treating neurologist as per Safe Implementation of Thrombolysis in Stroke criteria. There were 206 patients treated with IV tPA (mean age: 71.0 years; range: 24-92 years), of whom 65/206 (32%) were aged ≥80 years. Overall, HT occurred in 41/206 patients (20%), HI in 31, PH1 in four (one symptomatic) and PH2 in six (three symptomatic). Age was not associated with HT (any HT: odds ratio [OR]=1.01; 95% confidence interval [CI]=0.5-2.08; p=0.99; PH: OR=0.53; 95% CI=0.12-2.3; p=0.51). There was one patient with PH1 and one patient with PH2 in 65 patients ≥80 years, both asymptomatic. LA was present in 112/208 (54%), and severe in 16.5%. LA increased with age (p