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Background & Objective: Computed tomography angiography (CTA) in acute stroke has been widely used to demonstrate arterial occlusion. Alberta Stroke Program Early CT Score (ASPECTS) is used to detect early ischemic signs in non-contrast computed tomography (NCCT) in the middle cerebral artery region. We hypothesized that computed tomography angiography source image (CTA-SI) is superior to NCCT in predicting final infarct volume, 24 hour National Institutes of Health Stroke Scale (NIHSS) score and 90-day clinical outcome. Methods: Patients who had an acute ischemic stroke due to middle cerebral artery (MCA) occlusion and treated with tissue plasminogen activator (tPA) were retrospectively evaluated. ASPECTS was evaluated by two experienced stroke neurologists in acute NCCT, CTA-SI, and follow up imaging. The final ASPECTS was compared with the mean baseline ASPECTS of NCCT and CTA-SI. The relation of both scores with 24-hour NIHSS and clinical outcome was compared. The Modified Rankin Scale (mRS) was utilized to evaluate the 90-day outcomes. mRS score of 0-2 was considered a “good outcome”. Results: Fifty-three patients were evaluated. We observed a significant relation among CTA-SI ASPECTS and after treatment 24hr ASPECTS (y= -3.9 + 1.4 x; 95% CI, -7.6 to -0.2) (y= -26.04 + 3.5 x; CI, -41 to -10). The median baseline 24-hr NHISS was 6 (0 - 22). We found a better correlation between CTA-SI ASPECTS and 24-hr NHISS (y= 363.06 + -37.03 x; CI, -148 to 864) than between NCCT ASPECTS and 24h NHISS (y=529.80 + -62.55 x; CI, 180 - 829). Median 90 days mRS score was 2 (0 - 6). According to Deming regression analysis, the CTA-SI ASPECTS (y= 76.10 + -7.69 x; 95% CI, -36 to 188) was more consistent with the 90 day mRS compared to NCCT ASPECTS (y=149.86 + -17.67 x; 95% CI, 23 - 267) CTA-SI was superior in predicting 24hr NIHSS and day 90 mRS compared to NCCT ASPECTS. Conclusion: Prediction of CTA-SI ASPECTs is better than NCCT ASPECTs at 24hr NIHSS, 3-month mRS and final infarct size in acute ischemic stroke patients treated with tPA.

Brain edema is a common problem after stroke. Elevation of intracranial pressure causes high mortality anad morbidity rates by impairing cerebral perfusion and causing cerebral herniation. The neurologist who take care of acute stroke patients should guess the possibility of brain edema, take precautions for the development of brain edema, diagnose intracranial pressure elevation and cerebral herniation both clinically and raidologically, and treat brain edema rapidly. This expert opinion is a consensus declaration of 60 Neurologists who work on cerebrovascular diseases and neurocritical care under Turkish Society of Cerebrovascular Diseases.

In acute ischemic stroke due to large vessel occlusion; endovascular interventions in which the clot is removed mechanically are gold standard treatments. According to the guidelines and the results of the studies carried out in previous years, current practice is; If the patient does not have contraindications, IV rtPA is initiated before endovascular treatment without loss of time. However, in recent years there is a tendency in the direction of taking patients directly into the angiography unit and randomized controlled studies comparing these two groups are gaining weight. For direct endovascular intervention of patients; results have also been obtained showing that it may not be worse than combined therapy in recent studies. In the light of current studies, it is not yet possible to make clear choices between both approaches. For this reason, it would be a more logical approach to consider each patient separately and to make the right choice on the basis of the patient.

The Alberta Stroke Program Early Computed Tomography Score (ASPECTs) on noncontrast CT (NCCT) is widely used for the decision of endovascular therapy (ET) in randomized controlled trials. CT angiography source images (CTA-SI) is another method to evaluate ischemic brain damage. We aimed to evaluate the association between pretreatment ASPECTs on CTA-SI and post-treatment clinical and radiological outcomes in acute stroke patients treated with ET. The association between both scores along with final infarct and outcome were analyzed. A total of 90 patients with successful recanalization were included in the study. The mean age was 59 ± 11.8. According to the results, CTA-SI ASPECTs was better correlated with final infarct than NCCT ASPECTs (p 0.001). In univariate analyzes, factors associated with good outcome were age, baseline NIHSS score, and presence of diabetes mellitus (p = 0.001, p = 0.002, p = 0.034, respectively). On the other hand, when an analysis differentiating patients by age was performed, 40 patients below 60 years of age had significantly better outcomes despite having higher baseline NIHSS scores (p = 0.002). Finally, in multivariate analyzes, only age and baseline NIHSS score were found to be independent predictors of good outcome (p = 0.003 for both). In conclusion, CTA-SI ASPECTs in patient selection for ET seems to be more useful than NCCT ASPECTs. However, both scoring modalities were not found to be independent predictors of good outcome. Outcomes are changeable for the younger population who could continue their lives with mild or no deficits despite having a relatively low initial ASPECTs.

Catastrophic antiphospholipid syndrome (CAPS) is a syndrome characterized by the presence of antiphospholipid antibodies and acute thrombosis of multiple organ systems. It causes small or large venous and arterial thrombotic occlusions and may be fatal if not aggressively treated. In this article, we aimed to present a case of possible CAPS with a deep thrombocytopenia and a cerebral infarction due to internal carotid occlusion and to emphasize that CAPS should be keep in mind in the differential diagnosis of young stroke patients.

Endovascular treatment modalities that directly retrieve the clot have become standard strategies in the care of acute ischemic stroke with major vessel occlusion in selected patient groups. The anesthetic strategy applied in the perioperative stage of endovascular treatment should be well determined in order to minimize loss of time and to maintain hemodynamic stability. Most retrospective studies in previous years have shown that conscious sedation may be more advantageous. However, in recent randomized controlled trials, it has not been shown that general anesthesia leads to worse neurological outcomes when compared to conscious sedation. In this review, the effect of anesthetic strategy selection on patient outcome will be presented in the context of recent publications.

Capsular warning syndrome is an important clinical entity because of its typical story, presentation and increased risk of symptom recurrence recurrence. Since the pathophysiology of this syndrome has not be fully understood, there is no consensus on the treatment approach. Furthermore, clinical deterioration may occur despite antiplatelet, anticoagulant or trombolytic treatments. We aimed to present three cases with capsular warning syndrome to discuss their clinical presentations, radiological findings and to underline that prevention of its progression to a completed stroke may be difficult.

Objective: The study aimed to evaluate the prognostic role of modified TAN collateral score in predicting functional independence in ischemic stroke patients, who underwent endovascular therapy. Introduction: Identifying the group of patients, who will benefit most from arterial recanalization in patients with acute ischemic stroke, is the basis of success. Collateral circulation is a physiological condition that protects the brain against ischemia and inhibits the growth of a damaged area. The presence of collaterals is a well-known determinant for functional independence. Numerous collateral scoring systems are used for this purpose. The aim of this study was to evaluate the prognostic role of modified TAN collateral score (MTCS) in predicting functional independence in patients, who received endovascular therapy. Materials and methods: Prospective data of 101 patients, who received endovascular therapy from the stroke team of Eskisehir Osmangazi University (ESOGU) between 2016 and 2017, were examined retrospectively for this purpose. Collateral assessments were performed in Computed Tomography Angiography (CTA) according to the modified TAN scoring system (< 50% refers to poor collateral status, >= 50% refers to good collateral status). Good clinical outcome was assessed as mRS 0-2 in the 3rd month. The TICI scoring system was used in the evaluation of recanalization. Patients treated within the first 6 h of symptom onset, patients with NCCT and contrast CTA, patients with internal carotid artery and middle cerebral artery occlusion were included in the study. Posterior system stroke was not included in the study. Conclusion: Of the 101 patients, 50 (49%) had poor MTCS. Presentation and 24th hour NIHSS values of the patients with poor MTCS were higher (p:0.003). The third month mRS values were low in patients with good MTCS on admission, while these values were high in patients, who presented with poor MTCS. Mortality rates were significantly higher in the patient group with poor collateral circulation score (32-5.9%) (p:0.001). No significant differences were found in the presentation ASPECT values and (TICI 2b/3) recanalization rates of the patients. The rate of futile recanalization was significantly higher in the group with poor collateral circulation (52-8%) (p:0.0001). Presentation glucose, NIHSS, mTAN, symptom-puncture time, and good ASPECT score were found to be predictive markers for good outcome by univariate analysis. The major risk factors were determined by performing multiple logistic regression analysis. Presentation glucose, NIHSS, and mTAN (OR:1.013, 1.29, 0.198, respectively) were found to be strong and independent predictors for good clinical outcome. According to Multiple Binary Logistic Regression analysis Backward-ward model, Baseline NIHSS, poor collaterals and baseline glucose are found as predictors for poor outcome. Discussion: This study shows that good collateral score is associated with good clinical response, small final infarct volume, third month low mRS, low admission, and 24-hour NIHSS rates. The likelihood of having long term prognosis is 7 fold higher in patients with poor collaterals. The use of the MTCS system is recommended and supported due to its easy and rapid applicability.

Cerebral air embolism is a potentially life-threatening complication of left-sided ablation procedures. We present a 51-year-old woman with cerebral air embolism during atrial fibrillation cryoballoon ablation. Taking a deep breath while removing the dilatator was the most likely mechanism in our case. The patient was successfully treated with hyperbaric oxygen therapy at early stage and was discharged without any neurological sequelae.