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Schwartzmann Y, Spektor S, Moscovici S, Jubran H, Metanis I, Jouaba T, Cohen JE, Gomori JM, Leker RR. Comparison between moyamoya disease and moyamoya syndrome in Israel. J Stroke Cerebrovasc Dis 2024; 33:107635. [PMID: 38342272 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 01/23/2024] [Accepted: 02/09/2024] [Indexed: 02/13/2024] Open
Abstract
BACKGROUND AND AIMS Moyamoya is a chronic brain vasculopathy involving the distal intracranial internal carotid artery (ICA) or proximal middle cerebral artery (MCA). Moyamoya patients can be divided into those with primary moyamoya disease (MMD) and those with moyamoya secondary to other known causes such as intracranial atherosclerosis (moymoya syndrome [MMS]). Our aim was to compare the characteristics of MMD patients to those of MMS patients in a sample of Israeli patients seen over the course of 20 years at a tertiary referral center. METHODS Included patients were diagnosed with either MMD or MMS based on typical imaging findings and the presence or absence of known concomitant vascular risk factors or associated disorders and vascular disease. Patients with MMS were compared to those with MMD. Demographics, symptoms, signs, and radiological data were compared between the groups. Treatment options and long-term rates of recurrent stroke and functional outcome were also studied. RESULTS Overall, 64 patients were included (25 MMD, 39 MMS). Patients with MMD were significantly younger (median IQR 20 (7-32) vs. 40 (19-52); p=0.035). Patients with MMS more often had vascular risk factors but there were no significant differences in clinical presentations or long-term disability rates between the groups and a similar proportion of patients underwent surgical interventions to restore hemispheric perfusion in both groups (48% vs. 44% MMS vs. MMD; p=0.7). Almost one in four patient had a recurrent stroke after the initial diagnosis in both groups. Most recurrences occurred in the pre-surgery period in the MMS group and in the post-surgery period in the MMD group. CONCLUSIONS There were no statistically significant differences in clinical or radiological presentations between the MMS and MMD patients. The course is not benign with recurrent stroke occurring in as many as 25%. More data is needed in order to identify those at high risk for stroke occurrence and recurrence.
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Affiliation(s)
- Y Schwartzmann
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - S Spektor
- Departments of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - S Moscovici
- Departments of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | - H Jubran
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - I Metanis
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | - T Jouaba
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - J E Cohen
- Departments of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - J M Gomori
- Departments of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | - R R Leker
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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Lindgren E, Krzywicka K, de Winter MA, Sánchez van Kammen M, Heldner MR, Hiltunen S, Aguiar de Sousa D, Mansour M, Canhão P, Ekizoglu E, Rodrigues M, Silva EM, Garcia-Esperon C, Arnao V, Aridon P, Simaan N, Silvis SM, Zuurbier SM, Scutelnic A, Sezgin M, Alasheev A, Smolkin A, Guisado-Alonso D, Yesilot N, Barboza MA, Ghiasian M, Leker RR, Arauz A, Arnold M, Putaala J, Tatlisumak T, Coutinho JM, Jood K. A scoring tool to predict mortality and dependency after cerebral venous thrombosis. Eur J Neurol 2023. [PMID: 37165521 DOI: 10.1111/ene.15844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/22/2023] [Accepted: 04/24/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND We developed a prognostic score to predict dependency and death after cerebral venous thrombosis (CVT) to identify patients for targeted therapy in future clinical trials.. METHODS We used data from the International CVT Consortium. We excluded patients with pre-existent functional dependency. We used logistic regression to predict poor outcome (modified Rankin Scale 3-6) at 6 months and Cox regression to predict 30-day and 1-year all-cause mortality. Potential predictors derived from previous studies were selected with backward stepwise selection. Coefficients were shrunken using Ridge regression to adjust for optimism in internal validation. RESULTS Of 1454 patients with CVT, the cumulative number of deaths was 44 (3%) and 70 (5%) for 30 days and 1 year, respectively. Of 1126 patients evaluated regarding functional outcome, 137 (12%) were dependent or dead at 6 months. From the retained predictors for both models, we derived the SI2 NCAL2 C score utilizing the following components: absence of female Sex-specific risk factor, Intracerebral hemorrhage, Infection of the central nervous system, Neurologic focal deficits, Coma, Age, lower Level of hemoglobin (g/L), higher Level of glucose (mmol/L) at admission, and Cancer. C-statistics were 0.80 (95%CI 0.75-0.84), 0.84 (95%CI 0.80-0.88) and 0.84 (95%CI 0.80-0.88) for the poor outcome, 30 days and 1 year mortality model, respectively. Calibration plots indicated good model fit between predicted and observed values. The SI2 NCAL2 C score calculator is freely available at www.cerebralvenousthrombosis.com. CONCLUSIONS The SI2 NCAL2 C score shows adequate performance for estimating individual risk of mortality and dependency after CVT but external validation of the score is warranted.
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Affiliation(s)
- E Lindgren
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - K Krzywicka
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M A de Winter
- Department of Internal Medicine, UMC, Utrecht, Utrecht, the Netherlands
| | - M Sánchez van Kammen
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M R Heldner
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - S Hiltunen
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - D Aguiar de Sousa
- Stroke Centre, Centro Hospital Universitário Lisboa Central, Lisbon, Portugal
- CEEM and Institute of Anatomy, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - M Mansour
- Sina Hospital, Hamadan University of Medical Science, Hamadan, Iran
| | - P Canhão
- Department of Neurosciences and Mental Health (Neurology), Hospital de Santa Maria/CHULN; University of Lisbon, Lisbon, Portugal
| | - E Ekizoglu
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - M Rodrigues
- Department of Neurology. Hospital Garcia de Orta, Almada, Portugal
| | - E M Silva
- Department of Neurology. Hospital Garcia de Orta, Almada, Portugal
| | - C Garcia-Esperon
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | - V Arnao
- U.O.C. Neurologia con Stroke Unit A.R.N.A.S. Civico, Palermo, Italy
| | - P Aridon
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D), University of Palermo, Palermo, Italy
| | - N Simaan
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - S M Silvis
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S M Zuurbier
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A Scutelnic
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - M Sezgin
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - A Alasheev
- Department of Neurology, Sverdlovsk, Yekaterinburg, Russia
| | - A Smolkin
- Department of Neurology, Sverdlovsk, Yekaterinburg, Russia
| | - D Guisado-Alonso
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - N Yesilot
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - M A Barboza
- Neurosciences Department, Hospital Dr. R.A. Calderón Guardia, CCSS, San José, Costa Rica
| | - M Ghiasian
- Sina Hospital, Hamadan University of Medical Science, Hamadan, Iran
| | - R R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - A Arauz
- Instituto Nacional de Neurologia and Neurocirugia Manuel Velasco Suarez, Mexico-City, Mexico
| | - M Arnold
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - J Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - T Tatlisumak
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - J M Coutinho
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - K Jood
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Schwartzmann Y, Leker RR, Filioglo A, Molad J, Cohen JE, Honig A. Covid-19 associated free hanging clots in acute symptomatic carotid stenosis. J Neurol Sci 2023; 444:120515. [PMID: 36493703 PMCID: PMC9715260 DOI: 10.1016/j.jns.2022.120515] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 10/31/2022] [Accepted: 11/29/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Thrombotic complications including stroke were previously described following Covid-19. We aim to describe the clinical and radiological characteristics of Covid-19 related with acutely symptomatic carotid stenosis (aSCS). METHOD All patients presenting with an aSCS were prospectively enrolled in an ongoing institutional database. Inclusion criteria for the Covid-19-aSCS group were a combination of both antigen test and a positive reverse-transcriptase (PCR) test for Covid-19 upon admission. Patients with additional potential etiologies for stroke including cardioembolism, carotid dissection or patients with stenosis of <50% on CTA were excluded. A cohort of non-Covid-19 related aSCS patients admitted to the same institution before the pandemic during 2019 served as controls. RESULTS Compared to controls (n = 31), Covid-19-aSCS (n = 8), were younger (64.2 ± 10.7 vs 73.5 ± 10, p = 0.027), and less frequently had hypertension (50% vs 90%, p = 0.008) or hyperlipidemia (38% vs 77%, p = 0.029) before admission. Covid-19-aSCS patients had a higher admission NIHSS score (mean 9 ± 7 vs 3 ± 4, p = 0.004) and tended to present more often with stroke (88% vs 55%, p = 0.09) rather than a TIA. Covid-19-aSCS patients had higher rates of free-floating thrombus and clot burden on CTA (88% vs 6.5%, p = 0.002). Covid-19 patients also less often achieved excellent outcomes, with lower percentage of mRS score of 0 after 90-days (13% vs 58%, p = 0.022). CONCLUSION Covid-19- aSCS may occur in a younger and healthier subpopulation. Covid-19- aSCS patients may have higher tendencies for developing complex clots and less often achieve excellent outcomes.
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Affiliation(s)
- Y Schwartzmann
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - R R Leker
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - A Filioglo
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - J Molad
- Department of Stroke & Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - J E Cohen
- Departments of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - A Honig
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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4
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Honig A, Molad J, Horev A, Simaan N, Sacagiu T, Figolio A, Gomori JM, Hallevi H, Seyman E, Rotschild O, Alguayn F, Star MJ, Jonas-Kimchi T, Sadeh U, Cohen JE, Leker RR. Predictors and Prognostic Implications of Hemorrhagic Transformation Following Cerebral Endovascular Thrombectomy in Acute Ischemic Stroke: A Multicenter Analysis. Cardiovasc Intervent Radiol 2022; 45:826-833. [PMID: 35296934 DOI: 10.1007/s00270-022-03115-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 03/01/2022] [Indexed: 12/26/2022]
Abstract
PURPOSE Hemorrhagic transformation (HT) following cerebral endovascular thrombectomy (EVT) for large vessel occlusion (LVO) in acute ischemic stroke is associated with poor outcome. Recent studies have shown that EVT can be efficacious in imaging-selected patients as late as 6-24 h from onset (late time window; LTW). We sought to determine predictors and prognostic implications of HT following EVT in LTW. METHODS Consecutive patients undergoing EVT for LVO were recruited into a prospective multicenter database. HT was divided into petechial hemorrhagic-infarction and parenchymal hematoma (PH) type 1 or 2 defined as confluent hemorrhage covering < or > than 1/3 of the infarct volume, respectively. Multivariate analyses were performed to determine variables associated with HT subtypes. RESULTS Among 611 patients included (mean age 70.5 ± 12.5 years; median NIHSS 16), 115 (18.8%) had HT and 33 of them (5.4%) had PH2. Independent PH2 predictors included failed recanalization (OR 7.0, 95% CI 2.3-21.6), longer time from symptom onset to admission (OR 1.002 per minute 95% CI 1.001-1.003) and hyperlipidemia (OR 3.12; 95%CI 1.12-8.7). HT was not associated with outcome. In contrast, PH2 patients had lower favorable outcome rates (14.3 vs 41.6%, p = 0.004) and higher mortality rates (39 vs 17%, p = 0.001). Patients who underwent EVT in the late versus early window had similar PH2 rates (4.5 vs 6.7%, p = 0.27). In multivariate models, PH2 tripled the odds of both 90-day poor outcome (OR 3.1, 95% CI 1.01-9.5) and 90-day mortality (OR 3.2, 95% CI 1.4-7.3). CONCLUSIONS PH2 following EVT is associated with increased mortality and unfavorable outcome rates. Rates of PH2 are not different between LTW patients and those treated < 6 h from symptom onset.
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Affiliation(s)
- A Honig
- Departments of Neurology, Hadassah-Hebrew University Medical Center, P.O. Box 12000, 91120, Jerusalem, Israel.
| | - J Molad
- Department of Stroke and Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - A Horev
- Department of Neurology, Soroka- University Medical Center, Beer-Sheva, Israel
| | - N Simaan
- Departments of Neurology, Hadassah-Hebrew University Medical Center, P.O. Box 12000, 91120, Jerusalem, Israel
| | - T Sacagiu
- Departments of Neurology, Hadassah-Hebrew University Medical Center, P.O. Box 12000, 91120, Jerusalem, Israel
| | - A Figolio
- Departments of Neurology, Hadassah-Hebrew University Medical Center, P.O. Box 12000, 91120, Jerusalem, Israel
| | - J M Gomori
- Department of Radiology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - H Hallevi
- Department of Stroke and Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - E Seyman
- Department of Stroke and Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - O Rotschild
- Department of Stroke and Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - F Alguayn
- Department of Neurology, Soroka- University Medical Center, Beer-Sheva, Israel
| | - M J Star
- Department of Neurology, Soroka- University Medical Center, Beer-Sheva, Israel
| | - T Jonas-Kimchi
- Departments of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - U Sadeh
- Departments of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - J E Cohen
- Departments of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - R R Leker
- Departments of Neurology, Hadassah-Hebrew University Medical Center, P.O. Box 12000, 91120, Jerusalem, Israel
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Filioglo A, Simaan N, Honig A, Heldner MR, von Rennenberg R, Pezzini A, Padjen V, Rentzos A, Altersberger VL, Baumgartner P, Zini A, Grisendi I, Aladdin S, Gomori JM, Pilgram-Pastor SM, Scheitz JF, Magoni M, Berisavac I, Nordanstig A, Psychogios M, Luft A, Gentile M, Assenza F, Arnold M, Nolte CH, Gamba M, Ercegovac M, Jood K, Engelter ST, Wegener S, Forlivesi S, Zedde M, Gensicke H, Tatlisumak T, Cohen JE, Leker RR. Outcomes after reperfusion therapies in patients with ACA stroke: A multicenter cohort study from the EVATRISP collaboration. J Neurol Sci 2022; 432:120081. [PMID: 34920158 DOI: 10.1016/j.jns.2021.120081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 11/28/2021] [Accepted: 12/01/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Patients with stroke secondary to occlusions of the anterior cerebral artery (ACA) often have poor outcomes. The optimal acute therapeutic intervention for these patients remains unknown. METHODS Patients with isolated ACA-stroke were identified from 10 centers participating in the EndoVascular treatment And ThRombolysis in Ischemic Stroke Patients (EVATRISP) prospective registry. Patients treated with endovascular thrombectomy (EVT) were compared to those treated with intravenous thrombolysis (IVT). Odds ratios with 95% confidence intervals (OR; 95%CI) were calculated using multivariate regression analysis. RESULTS Included were 92 patients with ACA-stroke. Of the 92 ACA patients, 55 (60%) were treated with IVT only and 37 (40%) with EVT (±bridging IVT). ACA patients treated with EVT had more often wake-up stroke (24% vs. 6%, p = 0.044) and proximal ACA occlusions (43% vs. 24%, p = 0.047) and tended to have higher stroke severity on admission [NIHSS: 10.0 vs 7.0, p = 0.054). However, odds for favorable outcome, mortality or symptomatic intracranial hemorrhage did not differ significantly between both groups. Exploration of the effect of clot location inside the ACA showed that in patients with A1 or A2/A3 ACA occlusions the chances of favorable outcome were not influenced by treatment allocation to IVT or EVT. DISCUSSION Treatment with either IVT or EVT could be safe with similar effect in patients with ACA-strokes and these effects may be independent of clot location within the occluded ACA.
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Affiliation(s)
- A Filioglo
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - N Simaan
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - A Honig
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - M R Heldner
- Department of Neurology, University Hospital Bern, Switzerland
| | - R von Rennenberg
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin Institute of Health, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - A Pezzini
- Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Italy
| | - V Padjen
- Neurology Clinic, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - A Rentzos
- Department of Diagnostic and Interventional Neuroradiology, Sahlgrenska University Hospital and Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sweden
| | - V L Altersberger
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland
| | - P Baumgartner
- University Hospital Zurich and University of Zurich, Switzerland
| | - A Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - I Grisendi
- Neurology Unit, Stroke Unit, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - S Aladdin
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - J M Gomori
- Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - S M Pilgram-Pastor
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - J F Scheitz
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin Institute of Health, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - M Magoni
- U.O Vascular Neurology, Stroke Unit, ASST Spedali Civili, Brescia, Italy
| | - I Berisavac
- Neurology Clinic, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - A Nordanstig
- Department of Clinical Neurosciences, Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - M Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel and University of Basel, Switzerland
| | - A Luft
- University Hospital Zurich and University of Zurich, Switzerland
| | - M Gentile
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - F Assenza
- Neurology Unit, Stroke Unit, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - M Arnold
- Department of Neurology, University Hospital Bern, Switzerland
| | - C H Nolte
- Department of Neurology, Charité-Universitätsmedizin Berlin, Center for Stroke Research, Berlin, Berlin Institute of Health, Berlin, Germany
| | - M Gamba
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - M Ercegovac
- Neurology Clinic, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - K Jood
- Department of Clinical Neurosciences, Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - S T Engelter
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland; Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Switzerland
| | - S Wegener
- University Hospital Zurich and University of Zurich, Switzerland
| | - S Forlivesi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - M Zedde
- Neurology Unit, Stroke Unit, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - H Gensicke
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Switzerland; Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Switzerland
| | - T Tatlisumak
- Department of Clinical Neurosciences, Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - J E Cohen
- Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - R R Leker
- Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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Honig A, Sacagiu T, Filioglo A, Simaan N, Kalish Y, Gomori JM, Horev A, Leker RR, Cohen JE. Clopidogrel underactivity is a common in patients with acute symptomatic severe carotid stenosis. J Neurol Sci 2021; 425:117450. [PMID: 33878658 DOI: 10.1016/j.jns.2021.117450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Clopidogrel is commonly used for secondary stroke prevention in patients with large vessel stenosis. Reduced Clopidogrel high on treatment platelet reactivity (CR) can lead to Clopidogrel underactivity (CU) causing acute thrombosis. However, the prevalence of CU among patients with acute symptomatic carotid disease remains unknown. Therefore, we aimed to find the prevalence and identify the predictors for CU among patients with acutely symptomatic carotid stenosis. PATIENTS AND METHODS Over the span of 14 months, CR was measured at the time of endovascular procedure in all patients undergoing angiography and stenting because of acute symptomatic carotid stenosis. Only patients treated per institutional protocol with a combination of Clopidogrel and Aspirin were included. CR was measured with VerifyNowP2Y12 reaction units (PRU) and CU was defined as PRU > 208. Patients with CU were compared to those without CU. RESULTS Thirty-five patients were included (mean age 71.3 ± 10, 76% men) and twelve (34.3%, mean age 71.8 ± 8.4, 58% men) had CU at the time of endovascular intervention. On univariate analysis more severe carotid stenosis was seen in CU patients (92.6 ± 6.5% vs 81.6 ± 13.6%, p = 0.013) and percent stenosis was independently associated with CU on multivariate analysis (p = 0.023). CONCLUSIONS CU is present in 1 of every 3 patients with acutely symptomatic carotid disease. The current results suggest that CR testing should become part of routine care in patients with acutely symptomatic carotid disease.
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Affiliation(s)
- A Honig
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | - T Sacagiu
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - A Filioglo
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - N Simaan
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Y Kalish
- Department of Hematology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - J M Gomori
- Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - A Horev
- Department of Neurology, Soroka- University Medical Center, Beer-Sheva, Israel
| | - R R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - J E Cohen
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Leker RR, Farraj A, Sacagiu T, Honig A, ElHasan HA, Gomori JM, Cohen JE. Atrial Fibrillation Treatment Adequacy and Outcome after Endovascular Thrombectomy. J Stroke Cerebrovasc Dis 2020; 29:104948. [PMID: 32689630 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104948] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 04/12/2020] [Accepted: 05/06/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) often leads to large vessel occlusions (LVO) which may necessitate endovascular thrombectomy (EVT). Whether the adequacy of treatment with oral anticoagulants (OAC) prior to LVO modifies outcomes remains unknown. PATIENTS AND METHODS Consecutive EVT-treated LVO patients were recruited and the data was analyzed retrospectively. We combined patients with known AF that were untreated with OAC or inadequately treated with those with new-onset AF to form a group of undertreated-AF patients and compared them to adequately treated AF patients. RESULTS Of the 230 patients included, 109 (47%) had AF (86 known AF, 23 new-onset AF). AF patients were significantly older and more often reached favorable recanalization but less often had favorable outcomes compared to those without AF. Most patients with known AF (76%) were inadequately treated at stroke onset. Patients with undertreated-AF more often received tPA prior to EVT (26% vs. 4% p=0.009), more often had favorable collaterals (65% vs. 33% p<0.001) and more often reached favorable outcomes (28% vs. 9%, p=0.047) compared to adequately treated AF patients. On multivariate analyses adequately treated AF did not impact survival (Odds Ration [OR] 0.89 95% Confidence Interval [CI] 0.23-3.43), chances for favorable recanalization (OR 0.57 95%CI 0.15-2.13) or favorable outcome (OR 5.95 95%CI 0.62-57.39). CONCLUSIONS Treatment adequacy does not affect the rates of favorable functional outcome or survival in AF patients with LVO.
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Affiliation(s)
- R R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | - A Farraj
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | - T Sacagiu
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | - A Honig
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | - H Abu ElHasan
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | - J M Gomori
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | - J E Cohen
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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Affiliation(s)
- A. Honig
- Vancouver Stroke Program Division of Neurology University of British Columbia Canada
- Department of Neurology Hadassah‐Hebrew University Medical Center Jerusalem Israel
| | - R. R. Leker
- Department of Neurology Hadassah‐Hebrew University Medical Center Jerusalem Israel
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Schellinger PD, Shuaib A, Köhrmann M, Liebeskind DS, Jovin T, Hammer MD, Sen S, Huang DY, Solander S, Gupta R, Leker RR, Saver JL. Reduced mortality and severe disability rates in the SENTIS trial. AJNR Am J Neuroradiol 2013; 34:2312-6. [PMID: 23828106 DOI: 10.3174/ajnr.a3613] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The Safety and Efficacy of NeuroFlo Technology in Ischemic Stroke trial showed a trend for reduced all-cause mortality and positive secondary safety end point outcomes. We present further analyses of the mortality and severe disability data from the Safety and Efficacy of NeuroFlo Technology in Ischemic Stroke trial. MATERIALS AND METHODS The Safety and Efficacy of NeuroFlo Technology in Ischemic Stroke trial was a multicenter, randomized, controlled trial that evaluated the safety and effectiveness of the NeuroFlo catheter in patients with stroke. The current analysis was performed on the as-treated population. All-cause and stroke-related mortality rates at 90 days were compared between groups, and logistic regression models were fit to obtain ORs and 95% CIs for the treated versus not-treated groups. We categorized death-associated serious adverse events as neurologic versus non-neurologic events and performed multiple logistic regression analyses. We analyzed severe disability and mortality by outcomes of the mRS. Patient allocation was gathered by use of a poststudy survey. RESULTS All-cause mortality trended in favor of treated patients (11.5% versus 16.1%; P = .079) and stroke-related mortality was significantly reduced in treated patients (7.5% versus 14.2%; P = .009). Logistic regression analysis for freedom from stroke-related mortality favored treatment (OR, 2.41; 95% CI, 1.22, 4.77; P = .012). Treated patients had numerically fewer neurologic causes of stroke-related deaths (52.9% versus 73.0%; P = .214). Among the 90-day survivors, nominally fewer treated patients were severely disabled (mRS 5) (5.6% versus 7.5%; OR, 1.72; 95% CI, 0.72, 4.14; P = .223). Differences in allocation of care did not account for the reduced mortality rates. CONCLUSIONS There were consistent reductions in all-cause and stroke-related mortality in the NeuroFlo-treated patients. This reduction in mortality did not result in an increase in severe disability.
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Krakovsky M, Polianski V, Nimrod A, Higazi A, Leker RR, Lamensdorf I. THR-18, a 18-mer peptide derived from PAI-1, is neuroprotective and improves thrombolysis by tPA in rat stroke models. Neurol Res 2013; 33:983-90. [DOI: 10.1179/1743132811y.0000000018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Omary R, Chernoguz D, Lasri V, Leker RR. Decompressive hemicraniectomy reduces mortality in an animal model of intracerebral hemorrhage. J Mol Neurosci 2012; 49:157-61. [PMID: 23152135 DOI: 10.1007/s12031-012-9922-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2012] [Accepted: 11/05/2012] [Indexed: 11/25/2022]
Abstract
Decompressive hemicraniectomy (DHC) significantly reduces mortality in patients with large hemispheric ischemic strokes but has not been studied in intracranial hemorrhage (ICH). Male Sabra mice were subjected to large experimental ICH. The animals then underwent DHC or sham surgery. Early (1 day post-op) and late (5 days post-op) mortality rates and neurological disability were monitored. The animals were perfusion-fixed at 5 days post-ICH induction, and their brains were studied for hematoma volume and presence of active caspase 3 as a measure of apoptotic death in the area surrounding the hematoma. Our results show that DHC significantly reduced early (7 vs. 75 %, p < 0.001) and late (46 vs. 83 %, p = 0.017) mortality after large ICH. No significant differences in neurological disability were observed between surviving animals in both groups. Hematoma volumes did not differ between the groups on histological evaluation. The number of active caspase 3-positive neurons at the hematoma boundary was significantly higher in animals that underwent DHC. In conclusion, DHC reduces early and late mortality after devastating ICH without changing the hematoma volumes and without notable effects on motor and sensory functions in survivors. Further evaluation of this method to reduce mortality in ICH patients is warranted.
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Affiliation(s)
- R Omary
- Peritz and Chantal Scheinberg Cerebrovascular Research Laboratory, Department of Neurology, Hadassah-Hebrew University Medical Center, P.O. Box 12000, Hadassah Ein Kerem, Jerusalem 91120, Israel
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Avraham Y, Dayan M, Lassri V, Vorobiev L, Davidi N, Chernoguz D, Berry E, Leker RR. Delayed leptin administration after stroke induces neurogenesis and angiogenesis. J Neurosci Res 2012; 91:187-95. [PMID: 23152300 DOI: 10.1002/jnr.23147] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2012] [Revised: 08/23/2012] [Accepted: 09/07/2012] [Indexed: 11/10/2022]
Abstract
Leptin is a potent AMP kinase (AMPK) inhibitor that induces neuroprotection, neurogenesis, and angiogenesis when administered immediately after stroke. To dissociate these effects, we explored the effects of delayed administration of leptin, at 10 days after stroke onset, on neurogenesis and angiogenesis after stroke. Sabra mice underwent photothrombotic stroke and were treated with vehicle or leptin given either as a single dose or in triple dosing, 10 days later. Newborn cells were labeled with bromodeoxyuridine. Functional outcome was studied with the neurological severity score for 90 days poststroke, and the brains were then evaluated via immunohistochemistry. Final infarct volumes did not differ between the groups. Exogenous leptin led to significant increments in the number of proliferating BrdU(+) cells in the subventricular zone and in the cortex abutting the lesion (2.5-fold and 1.4-fold, respectively). There were significant increments in the number of newborn neurons and glia (4- and 3.4-fold, respectively) in leptin-treated animals. Leptin also significantly increased the number of blood vessels in the perilesioned cortex. However, animals treated with leptin failed to demonstrate significantly better functional states. In conclusion, leptin induces neurogenesis and angiogenesis even when given late after stroke but does not lead to better functional outcome in this delayed-treatment paradigm. These results suggest that the main beneficial effects of leptin after stroke are associated with its early neuroprotective role rather than with its proneurogenic or proangiogenic effects.
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Affiliation(s)
- Y Avraham
- Department of Human Nutrition and Metabolism, Hebrew University Hadassah Medical Center, Jerusalem, Israel
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Avraham Y, Davidi N, Lassri V, Vorobiev L, Kabesa M, Dayan M, Chernoguz D, Berry E, Leker RR. Leptin induces neuroprotection neurogenesis and angiogenesis after stroke. Curr Neurovasc Res 2012; 8:313-22. [PMID: 22023616 DOI: 10.2174/156720211798120954] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Revised: 10/03/2011] [Accepted: 10/06/2011] [Indexed: 11/22/2022]
Abstract
Leptin is a potent AMP kinase (AMPK) inhibitor that is central to cell survival. Hence, we explored the effects of leptin on neurogenesis and angiogenesis after stroke. Neural stem cells (NSC) were grown as neurospheres in culture and treated with vehicle or leptin and neurosphere size and terminal differentiation were then determined. We then explored the effects of leptin on endogenous repair mechanisms in vivo. Sabra mice underwent photothrombotic stroke, were given vehicle or leptin and newborn cells were labeled with Bromo-deoxy-Uridine. Functional outcome was studied with the neurological severity score for 90 days post stroke and the brains were then evaluated with immunohistochemistry. In a subset of animals the brains were also evaluated for changes in the expression of leptin receptor and AMPK. In vitro, leptin led to a 2-fold increase in neurosphere size but did not change the differentiation of newborn cells. Following stroke, exogenous leptin led to a 4-fold increase in the number of NSC in the cortex abutting the lesion. There was a 1.5-fold increase in the number of newborn neurons and glia in leptin treated animals. Leptin also significantly increased the number of blood vessels in the peri-lesioned cortex. Leptin treated mice had increased expression of leptin receptor and increased phosphorylated AMPK concentration. Animals treated with leptin also had significantly better functional states. In conclusion, leptin induces neurogenesis and angiogenesis after stroke and leads to increased leptin receptor and pAMPK concentrations. This may explain at least in part the better functional outcome observed in leptin treated animals after stroke.
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Affiliation(s)
- Y Avraham
- Department of Human Nutrition and Metabolism, Hebrew University Hadassah Medical Center, Jerusalem, Israel
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Meiner Z, Cohen JE, Gomori JM, Sajin A, Schwartz I, Tsenter J, Yovchev I, Eichel R, Ben-Hur T, Leker RR. Rehabilitation outcomes of stroke patients treated with multi-modal endovascular reperfusion therapy. Eur J Phys Rehabil Med 2012; 48:31-37. [PMID: 21602761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
AIM The aim of this study was to investigate the influence of multi-modal endovascular reperfusion therapy (MMRT) on functional outcomes following rehabilitation. METHODS Data from 14 MMRT-treated patients were analyzed and compared to MMRT-ineligible, age and stroke severity-matched patients treated at the same Neurological and Rehabilitation departments. Neurological evaluation was assessed with the NIH stroke scale (NIHSS). Activity of daily living was measured using the FIMTM instrument. Functional outcome was measured using the modified Rankin scale (mRS). RESULTS The baseline characteristics of both groups were similar. NIHSS scores were lower in the MMRT group and they had slightly better functional and rehabilitation scores on admission to rehabilitation. At the end of rehabilitation, more MMRT-treated patients reached functional independence (mRS≤2; 50% vs. 7% respectively P=0.03). FIM scores were also higher in the MMRT group (mean score 93.3 vs. 87.7, respectively) but the difference did not reach significance. The delta in FIM and NIHSS scores obtained during rehabilitation did not significantly differ between the groups. MMRT remained a significant modifier of good outcome after regression analysis (OR 21.5 95% CI 1.1-410). CONCLUSION MMRT-treated patients have better chances of attaining independence after rehabilitation therapy. However, the additional improvements gained while in active rehabilitation were independent of reperfusion status.
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Affiliation(s)
- Z Meiner
- Departments of Physical Medicine and Rehabilitation, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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Arkadir D, Eichel R, Gomori JM, Ben Hur T, Cohen JE, Leker RR. Multimodal reperfusion therapy for large hemispheric infarcts in octogenarians: is good outcome a realistic goal? AJNR Am J Neuroradiol 2012; 33:1167-9. [PMID: 22300926 DOI: 10.3174/ajnr.a2916] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE MMRT may be beneficial in a subset of patients with large hemispheric stroke who cannot be treated with systemic thrombolysis. Because most previous studies only included relatively young patients, the outcome of very old patients given MMRT remains unknown. MATERIALS AND METHODS Consecutive patients with large hemispheric stroke treated with MMRT and admitted to intensive care were included. We compared neurologic and functional outcomes between patients younger and older than 80 years. RESULTS We included 14 patients older than 80 years and compared them with 66 patients who were younger than 80. Cerebrovascular risk factor profile, admission NIHSS scores, stroke etiology and pathogenesis, and procedure-related variables did not differ between the groups except for a higher prevalence of smoking in younger patients. Excellent target vessel recanalization (Thrombolysis in Myocardial Infarction score of 3) and good outcome at 90 days (modified Rankin Score ≤ 2) were more common in younger patients (45% versus 14%, P = .047, and 41% versus 0%, P = .008, respectively). In contrast, mortality rates were higher in octogenarians (43% versus 17%, respectively). CONCLUSIONS In this study, very old patients had higher chances of mortality and a very low probability of achieving functional independence even after MMRT. Further prospective studies are needed to examine the futility of MMRT in the very old.
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Affiliation(s)
- D Arkadir
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Thau-Zuchman O, Shohami E, Alexandrovich AG, Leker RR. Subacute treatment with vascular endothelial growth factor after traumatic brain injury increases angiogenesis and gliogenesis. Neuroscience 2011; 202:334-41. [PMID: 22173016 DOI: 10.1016/j.neuroscience.2011.11.071] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2011] [Revised: 11/29/2011] [Accepted: 11/30/2011] [Indexed: 11/29/2022]
Abstract
Vascular endothelial growth factor (VEGF) is neuroprotective and induces neurogenesis and angiogenesis when given early after traumatic brain injury (TBI). However, the effects of VEGF administration in the subacute phase after TBI remain unknown. Mice were subjected to TBI and treated with vehicle or VEGF beginning 7 days later for an additional 7 days. The animals were injected with BrdU to label proliferating cells and examined with a motor-sensory scale at pre-determined time points. Mice were killed 90 days post injury and immunohistochemistry was used to study cell fates. Our results demonstrate that lesion volumes did not differ between the groups confirming the lack of neuroprotective effects in this paradigm. VEGF treatment led to significant increments in cell proliferation (1.9 fold increase vs. vehicle, P<0.0001) and angiogenesis in the lesioned cortex (1.7 fold increase vs. vehicle, P=0.0001) but most of the proliferating cells differentiated into glia and no mature newly-generated neurons were detected. In conclusion, VEGF induces gliogenesis and angiogenesis when given 7 days post TBI. However, treated mice had only insignificant motor improvements in this paradigm, suggesting that the bulk of the beneficial effects observed when VEGF is given early after TBI results from the neuroprotective effects.
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Affiliation(s)
- O Thau-Zuchman
- Department of Neurology and the Peritz and Chantal Scheinberg Cerebrovascular Research Laboratory, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Abstract
BACKGROUND Pre-treatment with cholesterol lowering drugs of the statin family may exert protective effects in patients with ischaemic stroke and subarachnoid haemorrhage but their effects are not clear in patients with intracerebral haemorrhage (ICH). METHODS We recruited patients admitted to our University Hospital with an acute ICH and analysed pre-admission demographic variables, pre-morbid therapy, clinical and radiological prognostic markers and outcome variables including 90-day modified Rankin score and NIH stroke scale score (NIHSS). RESULTS We recruited 399 patients with ICH of which 101 (25%) were using statins. Statin users more often had vascular risk factors, had significantly lower haematoma volumes (P = 0.04) and had lower mortality rates compared with non-users (45.6% vs. 56.1%; P = 0.11). However, statin treatment did not have a statistically significant impact on mortality or functional outcome on multiple logistic regression analysis. CONCLUSIONS Treatment with statins prior to ICH failed to show a significant impact on outcome in this analysis despite lower haematoma volumes.
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Affiliation(s)
- R Eichel
- Department of Neurology, Hebrew University Hadassah Medical Center, Jerusalem, Israel
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Arzy S, Newman JP, Ben-Hur T, Leker RR. PRIMARY PROGRESSIVE APHASIA: QUANTITATIVE ANALYSIS. Neurology 2008; 71:145-6. [DOI: 10.1212/01.wnl.0000316803.12639.6f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Abstract
Because ischemic neuronal death is triggered by several parallel mechanisms, a combination of drugs active against individual death-promoting mechanisms may have synergistic effects. Dexanabinol is a noncompetitive NMDA antagonist with anti-inflammatory effects and tempol is a nitroxide antioxidant. Therefore, we explored whether their combined use results in smaller infarct volumes as compared with their individual administration. Rats underwent permanent middle cerebral artery occlusion (PMCAO) and were given vehicle, dexanabinol alone, tempol alone, or a combination of dexanabinol and tempol (n = 13 per group) 1 h later. Five animals in each group were evaluated with a motor rating scale 24 h after PMCAO and the infarct volumes were then measured. The remaining animals were examined with motor and behavioral scales up to 30 days after PMCAO and their infarct volumes were then determined. Motor disability and water maze latencies at all time points examined and infarct volumes at days 1 and 30 were significantly reduced in all active treatment groups when compared with vehicle. However, no significant differences were observed between the active treatment groups. In conclusions, combination therapy with dexanabinol and tempol does not appear to have additional neuroprotective effects compared to those conferred by each agent alone even when administered at optimal timing and dosing. Therefore, a ceiling neuroprotective effect that is impossible to overcome may exist.
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Affiliation(s)
- A Teichner
- Department of Neurology, Hebrew University-Hadassah Medical School, Hadassah University Hospital, Jerusalem
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Abstract
Many similarities exist between cerebral ischemia and epilepsy regarding brain-damaging and auto-protective mechanisms that are activated following the injurious insult. Therefore, drugs that are effective in minimizing seizure-induced brain damage may also be useful in minimizing ischemic injury. Use of such drugs in stroke victims may have important clinical and financial advantages. Therefore, the authors conducted a Medline search of studies involving the use of anti-epileptic drugs (AEDs) as possible neuroprotectants and summarize the data. Most AEDs have been tested in animal models of focal or global ischemia and some were already tested in humans, for a possible neuroprotective effect. The existing data is rather scant and insufficient but it appears that only drugs that have multiple mechanisms of action seem to have some potential in conferring a degree of neuroprotection that could be clinically applicable to stroke patients. In conclusion, some of the newer AEDs show promise as possible neuroprotectants in the setup of acute ischemic stroke but more studies are needed before clinical trials in humans could be undertaken.
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Affiliation(s)
- R R Leker
- Department of Neurology and the Agnes Ginges Center for Human Neurogenetics, Hebrew University-Hadassah Medical School, Hadassah University Hospital, Jerusalem, Israel.
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Abstract
Traumatic brain injury is one of the most common causes for chronic disability in young people. Despite this there are currently no widely available modes of therapy that would limit the extent of brain damage secondary to trauma. Therefore, new insights into the pathological mechanisms involved in head trauma possibly leading to the identification of new therapeutic targets are urgently needed. In order to attain these goals adequate animal models for traumatic brain injury are needed. In the following paper the authors will review the various animal models for head trauma and emphasize their potential strengths and weaknesses.
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Affiliation(s)
- R R Leker
- Department of Neurology, Agnes Ginges Center for Human Neurogenetics, Hebrew University-Hadassah Medical School, Hadassah University Hospital, Jerusalem, Israel
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Abstract
Therapeutic options available for acute stroke management are sparse and inadequate. Therefore, new insights into stroke pathophysiology leading to new therapeutic targets are needed. In order to attain these goals, adequate animal models for cerebral ischemia are needed. In the following paper the authors will review the various animal models for stroke and emphasize their potential strengths and weaknesses.
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Affiliation(s)
- R R Leker
- Department of Neurology, Agnes Ginges Center for Human Neurogenetics, Hadassah University Hospital, Jerusalem, Israel
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Leiba A, Bar-Dayan Y, Leker RR, Apter S, Grossman E. Seizures as a presenting symptom of phaeochromocytoma in a young soldier. J Hum Hypertens 2003; 17:73-5. [PMID: 12571620 DOI: 10.1038/sj.jhh.1001499] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2002] [Accepted: 10/06/2002] [Indexed: 11/09/2022]
Abstract
New onset of seizures in young adults is frequently related to alcohol withdrawal, toxic exposure, central nervous system trauma and neoplasm. We describe a young soldier presenting to the emergency department with seizures and transient coma. On admission, he had hypertension, marked leukocytosis, hyper-glycaemia, acidosis, elevated creatinine and elevated creatine phosphokinase of muscle origin. A thorough work-up revealed elevated urinary catecholamines, and a left adrenal mass was found on MRI and MIBG scan. The patient underwent laparoscopic adrenalectomy and completely recovered. This is the first description of seizures as a presenting symptom of phaeochromocytoma.
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Affiliation(s)
- A Leiba
- Department of Internal Medicine D, The Chaim Sheba Medical Center, Tel-Hashomer, Israel
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Leker RR, Teichner A, Lavie G, Shohami E, Lamensdorf I, Ovadia H. The nitroxide antioxidant tempol is cerebroprotective against focal cerebral ischemia in spontaneously hypertensive rats. Exp Neurol 2002; 176:355-63. [PMID: 12359177 DOI: 10.1006/exnr.2002.7910] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Free radicals appear to participate in the final common pathway of neuronal death in ischemia and may therefore be an adequate target for therapy. Tempol is a nitroxide antioxidant with proven protective efficacy in several animal models, including myocardial ischemia, that has not been previously tested in models of permanent cerebral ischemia. Spontaneously hypertensive rats underwent permanent middle cerebral artery occlusion (PMCAO). Following dose-response and time-window-finding experiments rats were given vehicle or tempol (50 mg/kg) subcutaneously 1 h after PMCAO (n = 10/group). Five animals in each group were evaluated with a motor scale 24 h after the infarct and were then sacrificed and the injury volume was measured. The remaining animals were examined daily with the motor scale and also with a Morris water maze test on days 26-30 after PMCAO and sacrificed on day 30. Motor scores at all time points examined were significantly better in the tempol-treated animals (P < 0.05 for all). Significantly better performance in the water maze test for performance on days 26-30 was noted in the tempol group compared with the vehicle-treated group (P < 0.05). Injury volumes at days 1 and 30 were significantly reduced in the tempol group (9.83 +/- 1.05 vs 19.94 +/- 1.43% hemispheric volume, P = 0.0009, and 13.2 +/- 2.97 vs 24.4 +/- 2.38% hemispheric volume, P = 0.02, respectively). In conclusion, treatment with tempol led to significant motor and behavioral improvement and reduced injured tissue volumes both in the short and in the long term after stroke.
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Affiliation(s)
- R R Leker
- Department of Neurology, Agnes Ginges Center for Human Neurogenetics, Hebrew University-Hadassah Medical School, Hadassah University Hospital, Jerusalem 91120, Israel
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Leker RR, Teichner A, Ovadia H, Keshet E, Reinherz E, Ben-Hur T. Expression of endothelial nitric oxide synthase in the ischemic penumbra: relationship to expression of neuronal nitric oxide synthase and vascular endothelial growth factor. Brain Res 2001; 909:1-7. [PMID: 11478916 DOI: 10.1016/s0006-8993(01)02561-6] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Expressional patterns of the endothelial and neuronal forms of nitric oxide synthase (NOS) in cerebral ischemia were studied utilizing a permanent middle cerebral artery occlusion (PMCAO) model. Motor performance and infarct volumes were determined in the rats. Immunohistochemical staining for eNOS, nNOS and neurofilament were performed at 1, 2, 3, 5, 7 and 14 days after PMCAO. Vascular endothelial growth factor (VEGF) expression was determined by in-situ hybridization. PMCAO caused a reproducible cortical infarct with motor deficits in the rats. Double immunohistochemical stainings indicated that eNOS and nNOS were induced in ischemic neurons. Most stained neurons were positive for both NOS forms but some reacted with only one NOS antibody. nNOS expression peaked at 24-48 h after PMCAO, stained mainly the cytoplasm of core neurons, and disappeared after the 3rd day. eNOS expression increased until the 7th day, stained mainly the cytoplasm and membrane of penumbral cells and disappeared by the 14th day after PMCAO. VEGF expression was significantly induced in the penumbral zone in a similar distribution to eNOS. The anatomical and temporal pattern of VEGF and eNOS induction in the brain after permanent ischemia suggest that these mediators may play a role in protecting penumbral tissue from additional ischemic damage.
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Affiliation(s)
- R R Leker
- Department of Neurology and the Agnes Ginges Center for Human Neurogenetics, Hebrew University-Hadassah Medical School, Hadassah University Hospital, P.O. Box 12000, 91120, Jerusalem, Israel.
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27
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Abstract
Six patients who fulfilled strictly defined criteria for migrainous cerebral infarction and in whom other causes of stroke were ruled out were observed. All had a long-standing history of migraine with aura. In most, stroke was mild with good recovery and no recurrence. Headache frequency and severity decreased after the stroke. It is hypothesized that the improvement in migraine may be due to reduced nociceptive transmission as result of loss in vasoreactivity of the affected cerebral blood vessel.
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Affiliation(s)
- E Linetsky
- Department of Neurology, The Agnes Ginges Center for Human Neurogenetics, Hadassah-Hebrew University Hospital, Jerusalem, Israel
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Leker RR, Ben-Hur T. Re: cost and outcome of mechanical ventilation for life-threatening stroke. Stroke 2001; 32:1443-8. [PMID: 11387513 DOI: 10.1161/01.str.32.6.1443-c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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29
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Abstract
In order to test the long-term cerebroprotective effects of dexanabinol, a synthetic non-competitive NMDA antagonist that also has anti-TNFalpha effects, spontaneously hypertensive rats underwent permanent middle cerebral artery occlusion (PMCAO). Rats were given vehicle or dexanabinol (4.5 mg/kg) 1, 3 or 6 h after PMCAO. The research consisted of 2 stages. In the short-term set of experiments animals (n=5/group), were tested with a motor disability scale 24 h post PMCAO, then sacrificed and the infarct volume was measured using 2,3,5-Triphenyltetrazolium chloride (TTC) staining. In the long-term set of experiments the rats (n=7/group) were examined daily with a motor disability scale up to 30 days after PMCAO and then sacrificed and infarct volumes were determined using TTC staining. Motor scores were significantly improved in the dexanabinol treated rats (P<0.05 for all groups) at all the time points examined. Infarct volumes were significantly reduced 24 h after PMCAO in the groups treated 1 or 3 h, but not 6 h after PMCAO compared with vehicle (Mean+/-S.D., 11.5+/-2.02, 12+/-3.2 and 14.4+/-2.4% vs. 20.8+/-1.3% hemispheric volume respectively). The lesions remained significantly smaller in the dexanabinol groups 30 days after PMCAO (Mean+/-S.D., 24.49+/-1.9% vs. 8.1+/-0.6, 11.1+/-2.3 and 13.8+/-2.5% hemispheric volume in animals treated with vehicle vs. dexanabinol 1, 3 or 6 h after PMCAO respectively; P<0.05 for all). In conclusion, the extended therapeutic window and the multi-mechanistic durable neuroprotective effects of dexanabinol make it a promising candidate for future stroke therapy.
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Affiliation(s)
- G Lavie
- Department of Neurology, The Agnes Ginges Center for Human Neurogenetics, Hebrew University-Hadassah Medical School, Hadassah University Hospital, Ein Kerem, P.O. Box 12000, 91120, Jerusalem, Israel
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30
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Abstract
OBJECTIVES To evaluate the reasons for implementing artificial ventilation (AV) in patients with acute ischemic stroke (AIS), determine their outcome and characterize prognostic variables in these patients. METHODS Consecutive patients presenting with AIS were evaluated. All patients who received AV were treated in a neurological semi-intensive care setting. RESULTS Of the 173 patients included in the study, 27 (16%) needed AV, 16 (9%) received AV and five of these patients (31%) survived. The mean NIH stroke scale score prior to AV was 14.5+/-5.6 (vs. 9.1+/-6.2 in non-intubated patients, P=0.001). Six patients were ventilated because of neurological deterioration. Most of these patients had large hemispheric infarctions with evident herniation and midline shift on CT scans. The only one who survived the acute hospitalization did not recover and died within 3 months. In the other 10 patients, AV was instituted during cardiopulmonary decompensation (CPD). These patients generally fared better; four of them survived and were discharged after a lengthier hospital stay when compared to non-intubated patients. Variables associated with survival among intubated patients were a lower neurological disability score on admission and on day 7 after the stroke, and intubation during CPD. CONCLUSIONS Implementing AV in semi-intensive care settings does not seem to improve survival in AIS patients with neurological deterioration. Stroke patients who need AV during CPD and those that have less severe neurological deficits may have better chances for survival.
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Affiliation(s)
- R R Leker
- Department of Neurology, Hebrew University Hadassah Medical School and Hadassah Medical Center, Ein Kerem, P.O. Box 12000, 91120, Jerusalem, Israel.
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31
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32
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Abstract
To examine whether exacerbation of myasthenia gravis (MG) can be induced by changes in sex hormone levels we immunized 20 female Lewis rats with torpedo antigen to induce experimental autoimmune MG (EAMG). Ten of the animals underwent surgical ovariectomy prior to the induction of EAMG and 10 served as controls. Anti-acetylcholine receptor antibody (AChR-ab) titres and the degree of decrement on repetitive stimulation electromyography (REMG) at 3 Hz were obtained at base line and compared between rats with and without ovariectomy and a second control group of naïve rats. Three rats in each group were then injected with excess oestrogen and progesterone for one week, and three of the remaining rats in each group were given sham injections, and the degree of decrement on REMG and AchR-ab titres were re-evaluated. Immune reactivity of peripheral lymphocytes and splenic lymphocytes from all groups and controls was also determined. A comparable number of animals with and without ovariectomy developed clinical and electromyographic EAMG. The extent of decrement on REMG and AChR-ab titres did not change following hormonal replacement. Lymphocyte reactivity was similar for rats with and without ovariectomy. In conclusion, sex hormones do not appear to have an influence on the susceptibility to and the severity of MG.
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Affiliation(s)
- R R Leker
- Department of Neurology, Hadassah University Hospital, Hebrew University and Hadassah Medical School, Jerusalem, Israel.
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33
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DeKeyser FG, Leker RR, Weidenfeld J. Activation of the adrenocortical axis by surgical stress: involvement of central norepinephrine and interleukin-1. Neuroimmunomodulation 2000; 7:182-8. [PMID: 10810250 DOI: 10.1159/000026437] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
In the present study, we examined the mechanisms involved in the activation of the adrenocortical axis following surgical stress. Adult male rats underwent surgical laparotomy or craniotomy under ether anesthesia while control rats were only ether-anesthetized. Four hours following laparotomy or craniotomy, serum adrenocorticotropin (ACTH) and corticosterone (CS) were significantly increased and returned to almost basal levels after 24 h. Laparotomy also caused a significant depletion of corticotropin-releasing hormone (CRH-41) in the median eminence (ME). Pretreatment with dexamethasone 50 microg/kg completely abolished the pituitary-adrenal response while pretreatment with type II corticosteroid receptor antagonist caused a significant hypersecretion of both ACTH and CS and inhibited the effect of dexamethasone. The response to laparotomy was markedly attenuated in rats injected with 6-hydroxydopamine into the paraventricular nucleus (PVN) which significantly depletes norepinephrine (NE) PVN content. Intracerebroventricular injection of interleukin-1 receptor antagonist (IL-1ra) also inhibited the pituitary-adrenal response to laparotomy. The results suggest that (1) surgical stress activates the hypothalamo-pituitary-adrenal (HPA) axis via a mechanism which involves the release of CRH from the ME and NE input to the PVN; (2) the adrenocortical response is sensitive to the negative feedback of glucocorticoids via the mediation of type II glucocorticoid receptors, and (3) central IL-1 may be a mediator in the HPA axis response to surgical stress.
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Affiliation(s)
- F G DeKeyser
- School of Nursing, Hadassah University Hospital, Hebrew University-Hadassah Medical School, Jerusalem, Israel.
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34
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Abstract
The thalamus is a relay center for afferent sensory pathways that regulates and transmits peripheral stimulation to various representative areas of the cortex. Aphasia, neglect and anosognosia were also reported to occur after thalamic lesions, in the absence of cortical pathology. However, considerable controversy exists as to the pathogenetic mechanisms, and incidence of cognitive abnormalities following thalamic lesions. We present a series of sixteen consecutive stroke patients with thalamic stroke (n=12) or hemorrhage (n=4), admitted to a university based neurology department. Dysphasia was observed in seven of eight patients with left thalamic strokes (five in the territory of the tuberothalamic artery, two inferior-lateral thalamic lesions and one in the area supplied by the anterior choroidal artery). Neglect and anosognosia appeared in five of eight patients with right side thalamic insults (two each in the territories of the tuberothalamic and thalamogeniculate arteries and one in the area supplied by the posterior choroidal artery). These findings reconfirm those found in previous studies and suggest that the thalamus is part of an integral neuronal network concerned with cognitive functions.
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Affiliation(s)
- D Karussis
- Department of Neurology, Hadassah University Hospital, P.O. Box 12000, Jerusalem, Israel.
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35
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Abstract
To characterize dural sinus thrombosis (DST) patients presenting with a syndrome simulating pseudotumor cerebri (PTC), medical records of patients initially diagnosed as having PTC between 1980 and 1995 were analysed. Inclusion criteria were intracranial hypertension (IH) and a normal initial computed tomography (CT) scan. All patients underwent angiography or magnetic resonance imaging (MRI) and magnetic resonance venography (MRV). Patients with IH secondary to a determined disorder were excluded from the study. Forty-six patients were included, 12 patients had MRI/MRV or angiography findings compatible with DST and the remaining 34 patients had no vascular pathology on neuroimaging studies and were considered to have PTC. No clinical or auxiliary findings differed between the two groups except for younger age, which delineated the PTC patients. Two patients with DST died during the study. Both were agitated, had a relatively rapid course of symptom progression, and a CSF pressure of over 40 cm water. We conclude that DST can be identified in 26% of patients presenting with symptoms and signs typical of PTC. It may be impossible to differentiate between patients with and without DST if MRI/MRV or angiography are not performed in this scenario.
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Affiliation(s)
- R R Leker
- Department of Neurology, Hebrew University-Hadassah Medical School, Jerusalem, Israel.
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36
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Abstract
Alexia is usually seen after ischaemic insults to the dominant parietal lobe. A patient is described with a particular alexia to reading Hebrew (right to left), whereas no alexia was noted when reading in English. This deficit evolved after a hypertensive right occipitoparietal intracerebral haemorrhage, and resolved gradually over the ensuing year as the haematoma was resorbed. The deficit suggests the existence of a separate, language associated, neuronal network within the right hemisphere important to different language reading modes.
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Affiliation(s)
- R R Leker
- Department of Neurology, Hebrew University-Hadassah Medical School, Jerusalem, Israel.
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37
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Abstract
The permanent middle cerebral artery occlusion (PMCAO) model was used to investigate the cerebroprotective effects of the synthetic cannabinoid, dexanabinol (HU-211). Dexanabinol is a noncompetitive N-methyl-D-aspartate antagonist, with antioxidant and anti-TNFalpha properties. Twenty hypertensive rats were subjected to PMCAO. Eight were given 4 mg/kg dexanabinol, i.v., 1 h after PMCAO, eight received vehicle and four were not injected Five rats underwent sham surgery. Infarct volumes were assessed, as well as TNFalpha concentrations and NOS activity in brain homogenates. Dexanabinol significantly decreased infarct volumes. It also significantly lowered TNFalpha levels in the ipsilateral hemisphere although not to the level of sham operated rats. No effect could be demonstrated on NOS activity. In conclusion, dexanabinol may be a pluripotent cerebroprotective agent.
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Affiliation(s)
- R R Leker
- Department of Neurology, Hebrew University-Hadassah Medical School, Jerusalem, Israel.
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Leker RR, Pollak A, Abramsky O, Ben-Hur T. Abundance of left hemispheric embolic strokes complicating coronary angiography and PTCA. J Neurol Neurosurg Psychiatry 1999; 66:116-7. [PMID: 9886472 PMCID: PMC1736191 DOI: 10.1136/jnnp.66.1.116] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Steiner I, Cohen O, Leker RR, Rubinovitch B, Handsher R, Hassin-Baer S, Gilden DH, Sadeh M. Subacute painful lumbosacral polyradiculoneuropathy in immunocompromised patients. J Neurol Sci 1999; 162:91-3. [PMID: 10064176 DOI: 10.1016/s0022-510x(98)00282-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The syndrome of inflammatory subacute lumbosacral polyradiculoneuropathy (SLP) has been reported in acquired immunodeficiency syndrome (AIDS) patients in association with cytomegalovirus infection and is only partially amenable to anti-viral therapy. We report three cases of relatively benign inflammatory painful SLP in two non-AIDS, immunosuppressed patients and one who HIV-seroconversed at the time of clinical presentation. SLP developed: (1) in association with HIV seroconversion; (2) during ECHO virus infection in a patient with common variable immune deficiency; and (3) after a severe systemic infection that induced transient immunosuppression due to Epstein-Barr virus reactivation. This report expands the spectrum of viruses associated with acute and subacute lumbosacral polyradiculoneuropathy and may shed light on its possible pathogenesis.
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Affiliation(s)
- I Steiner
- Department of Neurology, Hadassah University Hospital, Jerusalem, Israel.
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Karussis D, Leker RR, Ashkenazi A, Abramsky O. A subgroup of multiple sclerosis patients with anticardiolipin antibodies and unusual clinical manifestations: do they represent a new nosological entity? Ann Neurol 1998; 44:629-34. [PMID: 9778261 DOI: 10.1002/ana.410440408] [Citation(s) in RCA: 97] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The presence of antibodies to cardiolipin (ACL Abs) has been reported in some patients suffering from multiple sclerosis (MS), especially of the "neuromyelitic" type. In addition, bright T2-imaging foci (unidentified bright objects) are occasionally detected on brain magnetic resonance imaging (MRI) scans, in patients with antiphospholipid syndrome. From a cohort of 100 patients with a probable or definite diagnosis of MS according to Poser's criteria, we isolated a subgroup of 20 patients (8 males and 12 females) consistently positive for ACL Abs. These patients were followed up neurologically for 1 to 3 years and brain MRI scanning and a complete autoimmune screening were performed. Nineteen (19 of 20) of our patients had the classic neuroimaging features of MS (multiple white-matter T2 bright foci on the MRI scan). The most common neurological syndrome was chronic, slowly progressing myelopathy (presenting as myelopathy, neuromyelitis optica, or spinocerebellar syndrome; 15 of 20), and optic neuropathy (6 of 20). Headache was a dominant symptom in 8 of 20 patients. Less common symptoms included cognitive and psychiatric disorders and chronic fatigue. The mean levels of ACL Abs were 38.8+/-28.2 GPL (normal values up to 7.5). Oligoclonal bands in the cerebrospinal fluid were detected in only 3 of 20 patients. Patients were treated with acetylsalycilic acid and occasionally with short courses of steroids. The progression of the chronic myelopathic/spinocerebellar syndrome was slower than expected in MS (only 2 patients deteriorated whereas 4 improved during a mean follow-up period of 20.8+/-7.1 months). We conclude that patients with probable or definite diagnosis of MS, and consistently elevated levels of ACL Abs show a slower progression and some atypical (for MS) features, such as persistent headaches and absence of oligoclonal bands in the cerebrospinal fluid. In these patients, other, presumably vascular, mechanisms may be involved in the pathogenesis of the neurological symptoms. Therefore, management should include antiplatelet or even anticoagulant agents.
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Affiliation(s)
- D Karussis
- Department of Neurology, Hadassah, Hebrew University Hospital, Jerusalem, Israel
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41
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Abstract
BACKGROUND Anticardiolipin antibodies (ACL-Ab) are associated with various neurologic syndromes, but idiopathic intracranial hypertension (IIH) has only rarely been reported in this context. OBJECTIVES To delineate the frequency and clinical and radiological features of, as well as the cause-and-effect relationship between, ACL-Ab and IIH. METHODS We analyzed the medical records of patients with IIH hospitalized between January 1989 and September 1995. All patients underwent magnetic resonance imaging or magnetic resonance venography or angiography. Excluded were patients with intracranial hypertension due to dural sinus thrombosis or traumatic, structural, neoplastic, or infectious disorders. Patients who were found on at least 2 separate occasions to have increased IgG titers of ACL-Ab were identified and compared with patients without ACL-Ab. RESULTS Six (43%) of 14 patients with IIH had ACL-Ab. No differences in clinical, laboratory, or radiological variables could be found between patients with and without ACL-Ab. Only 3 of the 11 ACL-Ab-positive patients had previous systemic or neurologic abnormalities associated with ACL-Ab. CONCLUSIONS Anticardiolipin antibodies may cause IIH through mechanisms unrelated to major venous thrombosis. Idiopathic intracranial hypertension is frequently associated with ACL-Ab and can be the presenting symptom of the antiphospholipid syndrome. There are no major clinical, laboratory, or radiological features that distinguish between patients with IIH with and without ACL-Ab.
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Affiliation(s)
- R R Leker
- Department of Neurology, Hebrew University, Hadassah University Medical Center, Jerusalem, Israel.
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42
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Abstract
Anticoagulants are generally contraindicated in patients with intracerebral hematoma. However, in patients with prosthetic heart valves it may be dangerous to withhold such therapy because of possible thromboembolic complications. We treated four such patients with i.v. heparin starting early after the hemorrhage. The hematomas receded in all patients according to the follow-up CTs, and none had thromboembolic disorders. Three patients had good outcomes, and one remained in a persistent vegetative state after an event of acute pulmonary edema.
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Affiliation(s)
- R R Leker
- Department of Neurology, Hebrew University-Hadassah Medical School, Jerusalem, Israel
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43
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Abstract
BACKGROUND Myasthenia gravis (MG) is an autoimmune disorder mediated by antiacetylcholine receptor antibodies. It has long been suspected to exacerbate during the menstrual period but this has never been adequately documented. SUBJECTS AND METHODS We questioned 120 female myasthenic patients of different ages, about their myasthenic symptoms before and during the menstrual period. We also evaluated the effect of medications, pain and stress during or before the menstrual period on the exacerbation rate. Exclusion criteria were postmenopausal age and incomplete information available in the questionnaire. RESULTS Forty two premenopausal women with generalized disease were included in the study. Twenty eight (67%) of the patients reported exacerbation of their myasthenic symptoms 2 to 3 days prior to the menstrual period. This exacerbation persisted in 22 of them to the third day of the menstrual period. In nine of the women this clinical worsening necessitated an increased intake of medications during the days prior to menstruation. No correlation could be found between the presence of antiacetylcholine receptor antibodies, pain, stress, use of oral contraceptives or the type of antimyasthenic therapy and the rate of exacerbation before and during the menstrual period. CONCLUSIONS (1) MG frequently exacerbates before and during the menstrual period in 67% of MG patients. (2) The rate of exacerbation is unrelated to the presence of stress or pain prior to or during the menstrual period. (3) Different therapies directed against MG, as well as oral contraceptives do not influence the clinical course. (4) Menstrual exacerbations occur in both seronegative and seropositive patients. (5) These exacerbations may frequently necessitate therapeutic changes.
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Affiliation(s)
- R R Leker
- Department of Neurology, Hadassah University Hospital, Hebrew University and Hadassah Medical School, Jerusalem, Israel.
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Leker RR, River Y. Atypical white matter changes in Alzheimer's disease. Eur Neurol 1997; 37:254-5. [PMID: 9208272 DOI: 10.1159/000117457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- R R Leker
- Department of Neurology, Hebrew University, Hadassah Medical School, Jerusalem, Israel.
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45
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Abstract
We report a patient who presented with a whole body microsomatoagnosia as part of an epileptic aura. We postulate that this rare phenomenon argues in favor of the existence of a whole body integrative neuronal networks which mediates the bodily awareness.
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Affiliation(s)
- R R Leker
- Department of Neurology, Hebrew University, Hadassah Medical Center, Jerusalem, Israel
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46
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Affiliation(s)
- R R Leker
- Israeli Defence Forces, Hadassah University Hospital, Jerusalem
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