Dissection and i-v alteplase treatment

Quereshi et al.  Arch Neurol 2011; 68: 1536-42

Authors reviewed database finding about 1 % of 48,000 stroke patients had an underlying dissection. Alteplase was less effective in this stroke type in lowering disability, but the rates of hemorrhage were similar to other stroke types, and the lower outcome was not due to alteplase therapy.

Cognitive and Neurologic Outcomes after CABG

Selnes, Gottesman, ....McKhann.  NEJM 2012; 366: 250-7  Review article

Bullet points  STROKE
1.  1.6 % rate overall, but rate may increase 10x if radiographic/clinically silent CVA's included

2.  Mechanism of micro/macroemboli with cross clamping needs to be modified to include hypotension and inflammatory response.  Caplan et al , proposed the combination of hypotension and microemboli leads to more injury because microemboli aren't washed out as readily.

3.  risk factors for neurologic morbidity: age, DM, HTN, history of stroke  Others:  PREOPERATIVE FACTORS (and odds ratio) :  athero of ascending aorta (2.0), h/o of TIA/CVA (2.1); h/o of subcortical disease (4.1), carotid stenosis (5.3); PVD (2); DM (1.2 or 2.8);HTN (1.8 or 1.3);  high pulse pressure (1.1);prior cardiac surgery (1.4); smoking history (1.6).     OPERATIVE FACTORS:  Hypotension (8.4); manipulation of aorta (1.8); bypass time > 2 hours (1.4).    POSTOP FACTORS: AD (.8 to 2.6). (article gives references for each risk factor).

4.  PREVENTION:  Use of individualized factors, and use of preop or postop ASA which are both controversial.  Use of eipaortic ultrasound to guide decision to cross clamp.  Use of carotid screening preop.  Avoiding combined carotid/coronary procedures.  All of these ideas have limited data.  Operative monitoring with TCD or near infraredspectroscopy has been used. 

COGNITIVE DECLINE

Factors include:
1.  preop cognitive abilities/disabilities
2,  

Recovery after spinal cord infarcts; long term outcomes in 115 patients

Neurolgy 2012;;78: 114-121  Robertson, Brown, Wijdicks, and Rabinstein.  Mayo Clinic

Authors debunk myths of spinal cord infarcts.  Retrospective study of patients show many improved over time.  Among their findings

1.  Gradual improvement was common after hospital dismissal. More than half walked aided or unaided eventually.

2. One third of those catheterised at dismissal did not require catheter long term

3. MRI's were frequently normal initially and even occassionally on followup MRI

4.  ASIA A/B predicted a poor outcome, but not invariably.  Other predictors of poor outcome included absent Babinski sign, sensory level, longitudinally extensive MRI, and lesions in highest thoracic level.  NON RISK FACTORS included age, mechanism, gender were not predictive of a poor functonal outcome

5.  There was a fairly high early mortality, around 26 % that was associated with HTN, DM, smoking, PVD, severity of impairment, and age (ie traditional risk factors mostly).

6.  Pain especially back pain was a common initial finding and a common longterm problem of survivors.

Lacune subtypes and risk factors

Authors divided lacunes into very small (<3 mm) and small (3-7 mm) and larger (8-20 mm).  The hypothesized mechanism for very small lacunes and small lacunes was lipohyalinosis and larger lacunes was microatheroma. 

Risk factors for small lacunes (lipohyalinosis) in 1548 patients analyzed included age, African American race, HTN, diabetes, ever smoking.   HBA1C could be substituted for DM. 

Very small lacunes had similar risk factors as small lacunes.  Diabetes was key risk factor here.

8-20 mm lacunes (microatheroma) were associated with ever smoking, age, and LDL levels.

Conclusion is that diabetes leads to disorder of systemic microcirculation leading to very small lacunes.  LDL and smoking lead to microatheroma