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Intravenous thrombolysis in probable cerebral amyloid angiopathy [Meeting Abstract]

Papamitsakis, N; Flusty, B
Introduction: The latest recommendations by the American Heart / Stroke Association on the use of intravenous thrombolysis for acute ischemic stroke suggest caution in patients with significant burden of cerebral microbleeds (CMBs). We describe such a patient, not previously diagnosed with cerebral amyloid angiopathy, treated with intravenous thrombolysis.65 year old man with diabetes, hypertension, hyperlipidemia, CAD on low dose aspirin at home, who became confused while playing poker, developing speech changes and perseveration to questions. He was brought to the ER and his initial NIHSS score was 3. CT head did not show hemorrhage. CTA head / neck did not show extraor intracranial vessel stenoses. He was treated with IV TPA within 3 hours of onset, without worsening of his symptoms. 24-hour head CT showed multiple subcortical hemorrhagic foci in both hemispheres. Brain MRI did not show an acute stroke on DWI. Multiple bilateral acute hemorrhages in each hemisphere were noted, along with innumerable microbleeds in the cerebrum and cerebellum bilaterally. The patient was transferred to acute rehabilitation where he had a generalized seizure.
Conclusion(s): In patients with multiple microbleeds, suggestive of cerebral amyloid angiopathy (CAA), the use of intravenous thrombolysis can lead to significant hemorrhagic conversion. Unfortunately, the majority of such patients does not have an established diagnosis of CAA or microbleeds previously, and might still be acutely treated with IV tPA
EMBASE:624946022
ISSN: 1747-4949
CID: 3516172

Intravenous TPA in the oldest old: A successful case of a 107 year old [Meeting Abstract]

Papamitsakis, N; Flusty, B
Introduction: The indications for intravenous thrombolysis for acute ischemic stroke have been expanded after the publication of the NINDS trial in 1995 using ages 18 to 80 as inclusion criteria. There are multiple reports of patients older than 80 treated with intravenous thrombolysis, and we are describing one of the oldest cases treated. 107 year old woman originally from the Dominican Republic (age confirmed after reviewing original documents including her passport) with history of hypertension, hyperlipidemia, diabetes, CAD, history of stroke 10 years earlier with mild right-sided residual deficits, and mild dementia, who collapsed while in the bathroom and was found then to have left sided weakness with left facial droop. NIHSS score was 14. The patient was given IV TPA 2 hours after symptom onset. CTA showed right ICA occlusion and severe stenosis of the left ICA, without significant intracranial occlusion/stenoses, and she was not considered endovascular treatment candidate. Brain MRI showed an acute right hemispheric, posterior parietal / occipital, ischemic stroke in the right posterior MCA / PCA territory. Her left-sided deficits had improved by the next day and the patient was discharged home four days later, able to walk with a walker. She was doing well when seen 4 months later.
Conclusion(s): The expansion of the criteria for the use of intravenous thrombolysis in acute ischemic stroke has shuttered the upper age limit. In otherwise appropriate candidates no maximum age limit should exist
EMBASE:624945997
ISSN: 1747-4949
CID: 3516182

Meningovascular syphilis with fatal vertebrobasilar occlusion [Case Report]

Feng, Wuwei; Caplan, Michael; Matheus, Maria G; Papamitsakis, Nikolaos I H
We report the case of a young patient with meningovascular syphilis who suffered fatal vertebrobasilar occlusion despite thrombolytic treatment and endovascular interventions. A 35-year-old man without any known medical history presented with an acute ischemic stroke and was initially treated with intravenous tissue plasminogen activator. He was then transferred to the stroke center, where he underwent endovascular recanalization of his occluded vertebrobasilar system. Despite initial successful recanalization, he suffered recurrent vertebrobasilar occlusion, and a second endovascular treatment attempt was unsuccessful. He subsequently developed a pontine hemorrhage and acute hydrocephalus and died secondary to transtentorial herniation. Laboratory findings were suggestive of prior spirochetal infection, and autopsy revealed necrotizing vasculitis and extensive adventitial inflammation involving the basilar and vertebral arteries, supporting the diagnosis of meningovascular syphilis.
PMID: 19680027
ISSN: 0002-9629
CID: 1740162

Cerebrovascular complications of Fabry's disease

Chapter by: Mitsias, Panayiotis; Papamitsakis, Nikolaos IH; Amory, Colum F; Levine, Steven R
in: Uncommon causes of stroke by Caplan, Louis R; Bogousslavsky, Julien [Eds]
Cambridge ; New York : Cambridge University Press, 2008
pp. 123-130
ISBN: 9780521874373
CID: 1747332

Spontaneous carotid artery dissection in a patient with Turner syndrome [Case Report]

Fuentes, Karel; Silveira, Diosely C; Papamitsakis, Nikolaos I H
PMID: 18042980
ISSN: 1421-9786
CID: 1740172

Eclamptic subarachnoid haemorrhage without hypertension [Case Report]

Moussouttas, Michael; Abubakr, Abuhuziefa; Grewal, Raji Pail; Papamitsakis, Nikolaos
Subarachnoid haemorrhage in pregnancy is often the result of aneurysmal rupture or severe hypertension. A young woman with postpartum eclampsia and 'normal' blood pressure developed sudden-onset head pain, and was found to have minor biconvexity subarachnoid hemorrhages. Serial angiograms of the cervicocranial vessels revealed no evidence of aneurysm or arteriovenous malformation. A follow-up angiogram revealed diffuse vessel narrowing, consistent with postpartum angiopathy. Treatment consisted only of nimodipine for the prevention of vasospasm. The patient made an excellent recovery, without residual neurological deficits.
PMID: 16678728
ISSN: 0967-5868
CID: 1740182

Combination antiplatelet agents in ischemic cerebrovascular disease

Moussouttas, Michael; Papamitsakis, Nikolaos
Combination antiplatelet agents with multiple mechanisms of action are being used with increasing frequency for vascular disorders, including cerebrovascular disease. Limited data exist regarding the efficacy of combination antiplatelet therapy in the primary or secondary prevention of cerebral ischemia, and combination therapies are often used without adequate evidence of efficacy. However, over the last few years, several cerebrovascular and cardiovascular trials have provided some preliminary information on the effectiveness of various combination therapies in preventing cerebral ischemic disease. This article reviews recently completed cerebrovascular and cardiovascular trials that tested a combination antiplatelet regimen against aspirin alone, and that assessed cerebral ischemia as an outcome measure. Controversies pertaining to these trials and to the use of the various combination antiplatelet regimens are discussed. Based on cardiovascular studies, clopidogrel in combination with aspirin has not been proven superior to aspirin alone for the primary prevention of cerebral ischemia. No data exists regarding the combination of clopidogrel and aspirin for the secondary prevention of cerebrovascular disease. The combination of aspirin plus extended-release dipyridamole (xrDP) appears to be superior to aspirin alone in the secondary prevention of cerebral ischemia, but may compromise cardiovascular protection in patients with coexisting coronary artery disease. Combination therapy with aspirin and clopidogrel seems to increase the risk of major hemorrhages, whereas aspirin plus xrDP does not. Ongoing trials are expected to clarify the role of various combination antiplatelet regimens.
PMID: 15682258
ISSN: 0027-2507
CID: 1740202

Amnestic syndrome of the subcallosal artery: a novel infarct syndrome [Case Report]

Moussouttas, Michael; Giacino, Joseph; Papamitsakis, Nikolaos
PMID: 15925871
ISSN: 1015-9770
CID: 1740192

Multiparametric iterative self-organizing MR imaging data analysis technique for assessment of tissue viability in acute cerebral ischemia

Mitsias, Panayiotis D; Ewing, James R; Lu, Mei; Khalighi, Mohammed M; Pasnoor, Mamatha; Ebadian, Hassan B; Zhao, Qingming; Santhakumar, Sunitha; Jacobs, Michael A; Papamitsakis, Nikolaos; Soltanian-Zadeh, Hamid; Hearshen, David; Patel, Suresh C; Chopp, Michael
BACKGROUND AND PURPOSE: Defining viability and the potential for recovery of ischemic brain tissue can be very valuable for patient selection for acute stroke therapies. Multiparametric MR imaging analysis of ischemic lesions indicates that the ischemic lesion is inhomogeneous in degree of ischemic injury and recovery potential. We sought to define MR imaging characteristics of ischemic lesions that are compatible with viable tissue. METHODS: We included patients with supratentorial ischemic stroke who underwent multiparametric MR imaging studies (axial multi-spin-echo T2-weighted imaging, T1-weighted imaging, and diffusion-weighted imaging) at the acute (< 24 hours) and outcome (3 months) phases of stroke. Using the algorithm Iterative Self-Organizing Data Analysis Technique (ISODATA), the lesion was segmented into clusters and each was assigned a number, called the tissue signature (white matter = 1, CSF = 12, all others between these two). Recovery was defined as at least a 20% size reduction from the acute phase ISODATA lesion volume to the outcome phase T2-weighted imaging lesion volume. The tissue signature data were collapsed into the following categories: < or = 3, 4, 5, and > or = 6. Logistic regression analysis included the following parameters: lesion volume, tissue signature value, apparent diffusion coefficient (ADC) value, relative ADC (rADC) expressed as a ratio, T2 value, and T2 ratio. The model with the largest goodness of fit value was selected. RESULTS: We included 48 patients (female-male ratio, 26:22; age, 64 [+/-14] years; 15 treated with recombinant tissue plasminogen activator [rt-PA] within 3 hours of onset; median National Institutes of Health Stroke Scale score, 7 [range, 2-26]). Median symptom onset-to-MR imaging time interval was 9.5 hours. With ISODATA processing, we generated 200 region-of-interest tissue records (one to nine tissue records per patient). Regarding tissue recovery, we detected a three-way interaction among ADC, ISODATA tissue signature, and previous treatment with rt-PA (P = .003). In the group not treated with rt-PA, ischemic tissues with acute rADC greater than the median (0.79) and tissue signature < or = 4 were more likely to recover (80% vs. 31% and 13%, odds ratio [95% CI]: 0.12 [0.05, 0.30] and 0.04 [0.01, 0.18] for tissue signatures 5 and 6, respectively). CONCLUSION: ISODATA multiparametric MR imaging of acute stroke clearly shows inhomogeneity and different viability of the ischemic lesion. Ischemic tissues with lower acute phase ISODATA tissue signature values (< or = 4) and higher rADC values (> or = 0.79) are much more likely to recover than those with higher signature values or lower rADC values. The effect of these factors on tissue recovery, however, is dependent on whether preceding treatment with rt-PA had been performed. Our approach can be a valuable tool in the design of therapeutic stroke trials with an extended time window.
PMID: 15502128
ISSN: 0195-6108
CID: 1740212

Treatment of acute supratentorial ischemic stroke with abciximab is safe and may result in early neurological improvement. A preliminary report

Mitsias, Panayiotis D; Lu, Mei; Morris, Dan; Silver, Brian; Lewandowski, Christopher; Papamitsakis, Nikolaos I; Khaligi, Mohammed M; Ebadian, Hassan B; Zhao, Qingming; Soltanian-Zadeh, Hamid; Daley, Sheila; Hearshen, David; Ewing, James R; Patel, Suresh C; Chopp, Michael
PMID: 15305070
ISSN: 1015-9770
CID: 1740222