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Biomedical subjects

L Remonda

Publications and source records attributed to L Remonda.

At least 19 recordsLinked to original sources
PubMed2006

Reasons to withhold intra-arterial thrombolysis in clinical practice.

BACKGROUND: In selected stroke centers intra-arterial thrombolysis (IAT) is used for the treatment of acute stroke patients presenting within 6 hours of symptom onset. However, data about eligibility of acute stroke patients for IAT in clinical practice are very scarce. METHODS: We collected prospectively data on indications advising for or against IAT of 230 consecutive stroke patients in a tertiary stroke center. RESULTS: 76 patients (33.0%) presented within 3 hours, 69 (30%) between 3 and 6 hours of symptom onset and 85 (37%) later than 6 hours. Arteriography was performed in 71 patients (31%) and IAT in 46 (20%). In 11 patients no or only peripheral branch occlusions were seen on arteriography and therefore IAT was not performed. In 9 patients the ICA was occluded and barred IAT and in five anatomical or technical difficulties made IAT impossible. 72 patients presenting within 6 hours did not undergo arteriography and thrombolysis, mostly because of mild (n=44) or rapidly improving neurological deficits (n=13). Other reasons to withhold IAT were CT and/or clinical findings suggesting lacunar stroke due to small vessel occlusion (n=7), limiting comorbidty (n=7) and baseline international normalized ratio>1.7 (n=1). CONCLUSIONS: A third of the patients underwent diagnostic arteriography and one fifth received IAT. The most important reasons to withhold thrombolysis were presentation beyond the 6 hours time window and mild or rapidly improving symptoms.

Adolescent↗
PubMed2005

[Balloon dilatation and Stentimplantation of the nasolacrimal duct for chronic epiphora].

PURPOSE: To examine the clinical outcome of the ballon dilatation in stenosis and obstruction of the nasolacrimal duct. MATERIAL AND METHODS: 63 patients (69 nasolacrimal duct systems) with epiphora and proven obstruction of the nasolacrimal duct were treated with ballon dilatation, respectively Stentimplantation. In 55 cases there was a pre- or postsaccal stenosis, in 14 cases an occlusion of the nasolacrimal duct system. The diagnosis was established by dacryocystography. RESULTS: Technical success was obtained in 61 cases (n=50/55 stenosis; n=11/14 occlusions). Over a mean follow-up of 6 months patency of the nasolacrimal duct system was achieved in 83,6% (46/55) in stenosis. In occlusion the clinical outcome was 42,9% (6/14). CONCLUSION: Balloon dacryocystoplasty and Stentimplantation are minimal-invasive alternatives, performed in local anesthesia that recover the normal anatomy of the nasolacrimal duct system. They are a good alternative in the treatment of epiphora caused by nasolacrimal duct obstructions.

Adult↗
PubMed2005

[Balloon dilatation of the canaliculus communis for chronic epiphora].

PURPOSE: To examine the clinical outcome of the balloon dilatation in stenosis of the canaliculus communis. METHOD: 18 nasolacrimal ducts with epiphora and proven obstruction of the canaliculus communis by dacryocystography (DCG) were treated with balloon dilatation in local anaesthesia. All patients were treated electively. RESULTS: In 16/18 cases the balloon dilatation was technically successful, in 2 patients the guide wire failed to pass the obstruction and the wire could not be placed in the nasal cavity. There were no complications. Over a mean follow-up of 6 months there were 2 reobstructions, one of these led to an occlusion of the canaliculus communis. 14/18 (77,8%) cases after DCP were treated successful, 11/18 cases were free of symptoms after DCP, in 4/18 cases the epiphora improved. CONCLUSIONS: Until recently in stenosis of the canaliculus communis the only therapeutic option was surgical procedure followed by silicone tube intubation. The results were often disappointing. In contrast to this balloon dacryocystoplasty is a minimally-invasive alternative in the therapy of stenosis of the canaliculus communis resulting in good clinical outcome during follow up.

Adult↗
PubMed2005

Comparison of intra-arterial thrombolysis with conventional treatment in patients with acute central retinal artery occlusion.

BACKGROUND: Several case series and a recent meta-analysis indicate that intra-arterial thrombolysis (IAT) is effective for the treatment of acute central retinal artery occlusion (CRAO). METHODS: A total of 37 patients with acute monocular blindness because of unilateral thromboembolic CRAO were treated with IAT using urokinase within six hours of the onset of symptoms. Visual outcome was compared with a control group of 19 patients, also seen within six hours, who did not undergo thrombolytic treatment. In both groups some patients were treated by paracentesis and/or acetazolamide. Predictors of visual outcome were evaluated. RESULTS: Visual improvement was more likely with IAT (p = 0.01) as were the chances to regain visual acuity of >0.6 significantly better (p = 0.04): 8/37 patients (22%) regained visual acuity of >0.6 in the IAT group and none (0/19) in the control group. Younger patients were more likely to regain some vision with (p = 0.012) or without IAT (p = 0.026). Three patients had minor treatment related cerebral ischaemic events, two had transient ischaemic attacks and one a minor stroke. There were no haemorrhagic complications. CONCLUSIONS: This series of patients with CRAO demonstrated that IAT enhanced the chances of visual improvement compared with conventional treatment only. Furthermore, younger patients have a better chance to achieve some visual recovery.

Acute Disease↗
PubMed2005

Ischaemic stroke in young adults: predictors of outcome and recurrence.

BACKGROUND: There is limited information about predictors of outcome and recurrence of ischaemic stroke affecting young adults. OBJECTIVE: To assess the predictive value of the presenting characteristics for both outcome and recurrence in young stroke victims. METHODS: Clinical and radiological data for 203 patients aged 16 to 45 years were collected prospectively; they comprised 11% of 1809 consecutive patients with ischaemic stroke. The National Institutes of Health stroke scale (NIHSS), the Bamford criteria, and the trial of ORG 10172 in acute stroke treatment (TOAST) classification were used to define stroke severity, subtype, and aetiology. The clinical outcome of 198 patients (98%) was assessed using the modified Rankin scale (mRS) and categorised as favourable (score 0-1) or unfavourable (score 2-6). RESULTS: Stroke was caused by atherosclerotic large artery disease in 4%, cardioembolism in 24%, small vessel disease in 9%, another determined aetiology in 30%, and undetermined aetiology in 33%. Clinical outcome at three months was favourable in 68%, unfavourable in 29%, and lethal in 3%. Thirteen non-fatal stroke, two fatal strokes, and six transient ischaemic attacks (TIA) occurred during a mean (SD) follow up of 26 (17) months. High NIHSS score, total anterior circulation stroke, and diabetes mellitus were independent predictors of unfavourable outcome or death (p<0.0001, p = 0.011, and p = 0.023). History of TIA predicted stroke recurrence (p = 0.02). CONCLUSIONS: Severe neurological deficits at presentation, total anterior circulation stroke, and diabetes mellitus predict unfavourable outcome. Previous TIA are associated with increased risk of recurrence.

Adolescent↗
PubMed2005

Recanalisation of middle cerebral artery occlusion after intra-arterial thrombolysis: different recanalisation grading systems and clinical functional outcome.

BACKGROUND: Different grading systems of arterial recanalisation have never been compared in large series of stroke patients treated with intra-arterial thrombolysis (IAT). METHODS: Clinical and angiographic findings and outcome were analysed in 147 patients with M1 or M2 segment occlusion of the middle cerebral artery treated with IAT. Associations of the thrombolysis in myocardial infarction (TIMI) grading system and the Mori grading system with clinical outcome were compared. RESULTS: The median NIHSS score on admission was 15 and the mean time from symptom onset to IAT was 242 minutes. After three months the outcome was favourable (defined as modified Rankin scale score (mRS) < or = 2) in 85 patients (58%) and poor (mRS 3 to 5) in 44 (30%); 18 patients (12%) were dead. Recanalisation was categorised as TIMI grade 0 in 17 patients (12%), TIMI 1 in 16 (11%), TIMI 2 in 83 (56%), and TIMI 3 in 31(21%). Seventeen patients (12%) showed Mori grade 0 reperfusion, 16 (11%) Mori 1, 37 (25%) Mori 2, 46 (31%) Mori 3, and 31 (21%) Mori 4. In both TIMI and Mori grading systems, reopening the artery was an independent predictor of a favourable clinical outcome (p < 0.0001). When recanalisation was partial, outcome was better in patients with reperfusion >50% (Mori 3) than in those with reperfusion <50% (Mori 2) (p = 0.008). CONCLUSIONS: Both TIMI and Mori grading systems are useful for predicting outcome after stroke and IAT. When recanalisation is partial the Mori classification is more refined in giving prognostic information.

Adolescent↗
PubMed2004

Locally induced hypothermia for treatment of acute ischaemic stroke: a physical feasibility study.

During the treatment of stroke by local intra-arterial thrombolysis (LIT) it is frequently possible to pass the blood clot with a micro-catheter, allowing perfusion of brain tissue distally to the occlusion. This possibility allows for new early treatments of ischaemic brain tissue, even before the blood clot has been removed. One potential new approach to preserve brain tissue at risk may be locally induced endovascular hypothermia. Physical parameters such as the required micro-catheter input pressure, output velocity and flow rates, and a heat exchange model, applicable in the case of a micro-catheter placed within a guiding catheter, are presented. Also, a simple cerebral temperature model is derived that models the temperature response of the brain to the perfusion with coolant fluids. Based on this model, an expression has been derived for the time needed to reach a certain cerebral target temperature. Experimental in vitro measurements are presented that confirm the usability of standard commercially available micro-catheters to induce local hypothermia of the brain. If applied in vivo, the model predicts a local cooling rate of ischaemic brain tissue of 300 g of approximately 1 degrees C in 1 min, which is up to a factor 30-times faster than the time-consuming systemic hypothermia via the skin. Systemic body temperature is only minimally affected by application of local hypothermia, thus avoiding many limitations and complications known in systemic hypothermia.

Algorithms↗
PubMed2004

Acute stenting and thromboaspiration in basilar artery occlusions due to embolism from the dominating vertebral artery.

Intra-arterial thrombolysis (IAT) is the only treatment that has demonstrated benefit in patients with acute basilar artery occlusions (ABAO). IAT may be difficult to perform when access to the occluded basilar artery (BA) is prevented by pathology of the vertebral arteries (VA). We report on two patients with ABAO due to embolism from the dominating VA. Catheter navigation through the occluded VA and thromboaspiration enabled access to the BA. Thromboaspiration alone or in addition to IAT resulted in a complete recanalization of the BA and a favorable clinical outcome. A stent was deployed at the site of the stenosis in the VA either prior to or immediately after BA recanalization.

Adult↗
PubMed2004

Clinical and radiological predictors of recanalisation and outcome of 40 patients with acute basilar artery occlusion treated with intra-arterial thrombolysis.

OBJECTIVE: To define predictors of recanalisation and clinical outcome of patients with acute basilar artery occlusions treated with local intra-arterial thrombolysis (IAT). METHODS: Vascular risk factors, severity of the neurological deficit graded by the National Institutes of Health stroke scale (NIHSS), and radiological findings were recorded at presentation. Outcome was measured using the modified Rankin scale (mRS) three months later and categorised as favourable (mRS 0-2), poor (mRS 3-5), or death (mRS 6). RESULTS: 40 patients were studied. Median NIHSS on admission was 18. Mean time from symptom onset to treatment was 5.5 hours (range 2.3 to 11). Outcome was favourable in 14 patients (35%) and poor in nine (23%); 17 (42%) died. There were two symptomatic cerebral haemorrhages (5%). Recanalisation of the basilar artery was achieved in 32 patients (80%); it was complete (TIMI grade 3) in 20% and partial (TIMI grade 2) in 60%. In multivariate logistic regression analysis, low NIHSS score on admission (p = 0.002) and vessel recanalisation (p = 0.005) were independent predictors of favourable outcome. Recanalisation occurred more often with treatment within six hours of symptom onset (p = 0.003) and when admission computed tomography showed a hyperdense basilar artery sign (p = 0.007). In a univariate model, quadriplegia (p = 0.002) and coma (p = 0.004) were associated with a poor outcome or death. CONCLUSIONS: Low baseline NIHSS on admission and recanalisation of basilar artery occlusions predict a favourable outcome after intra-arterial thrombolysis. Early initiation of IAT and the presence of a hyperdense basilar artery sign on CT were associated with a higher likelihood of recanalisation.

Acute Disease↗
PubMed2003

Diffusion-weighted MRI in acute spinal cord ischaemia.

Acute spinal cord ischaemia is often undetectable with conventional MRI. Diffusion-weighted MRI (DWI) has been difficult to use in the spine because of susceptibility artefacts. We assessed the diagnostic value of echoplanar DWI for early confirmation of spinal cord ischaemia. We performed conventional MRI and DWI in two men and three women, aged 54-75 years with clinically suspected acute spinal cord ischaemia. Imaging was performed 9-46 h after the onset of symptoms, and 2-9 days later to assess the extent of ischaemic signal change. Spatial resolution of DWI within the spine using standard equipment was poor, but in all patients, early DWI revealed areas of high signal indicating decreased diffusion, confirmed by measurement of apparent diffusion coefficients. Follow-up MRI showed high signal on T2-weighted images and contrast enhancement at the expected levels. Neurological deficits corresponded with radiological findings in four patients: various syndromes, including isolated bilateral weakness or sensory change and combined deficits, were found. Echoplanar DWI may be helpful for confirmation of spinal cord ischaemia in the acute stage, but follow-up T2-weighted images have superior spatial resolution and correlation with clinical findings and lesion extent.

Acute Disease↗
PubMed2003

[Stents in the treatment of supraaortic vessel stenosis].

We describe and discuss our experience of more than 500 endovascular procedures for revascularisation of acute or chronic occlusion and stenosis of supraaortic vessels using stents in 171 cases. Whereas endovascular treatment of the innominate, subclavian and vertebral arteries are routinely used in atherosclerotic occlusive lesions, carotid stenting is currently being investigated as an alternative treatment to carotid endarterectomy and seems to offer a less invasive, less traumatic and less cost expensive alternative to achieve the goal to prevent stroke. In a subgroup of high surgical risk patients carotid artery stenting with simultaneous embolic protection of the cerebral blood flow by filter systems was even superior to the endarterectomy-treated patients in a prospective, randomized multi-center study (SAPPHIRE): at 30-day follow up the major event rate for the stented group of 156 patients was 5.8% versus 12.6 for the 151 endarterectomy-treated patients.

Angiography↗
PubMed2003

[Therapeutic interventional neuroradiology in acute stroke].

Interventional neuroradiological techniques are described, which are used for revascularisation of the intra-extracranial vessels in acute stroke. The results are based on our experience gained during the endovascular treatment of more than 300 patients suffering from acute stroke during the last years. Indication, procedures and results of intraarterial thrombolysis, thrombo-aspiration, percutaneous transluminal angioplasty, and implantation of stents in cases of occlusion or pseudoocclusion of brain supplying vessels are discussed. Furthermore first experiences with new techniques from other centers are presented, e.g., thrombolysis by ultrasound (sonothrombolysis), by angiojet aspiration, and laser evaporation of the thromboembolic occlusion of intra- and extracranial blood vessels.

Acute Disease↗
PubMed2003

Intra-arterial thrombolysis in 24 consecutive patients with internal carotid artery T occlusions.

OBJECTIVES: To determine the safety, efficacy, and predictors of favourable outcome of intra-arterial thrombolysis in acute stroke attributable to internal carotid "T"occlusion METHODS: The authors analysed 24 consecutive patients with T occlusions of the internal carotid artery treated by local intra-arterial thrombolysis using urokinase. RESULTS: The median baseline National Institutes of Health Stroke Scale was 19. The average time from symptom onset to treatment was 237 minutes. Four patients (16.6%) had a favourable (modified Rankin Scale score (mRS</=2)) and 10 patients (41.7%) a poor outcome (mRS 3 or 4) after three months. Ten patients (41.7%) died. One symptomatic intracerebral haemorrhage (4.2%) occurred. Partial recanalisation of the intracranial internal carotid artery was achieved in 15 (63%), of the middle cerebral artery in four (17%), and of the anterior cerebral artery in eight patients (33%). Complete recanalisation never occurred. Sufficient leptomeningeal collaterals as seen on arteriography (p=0.02) and age <60 years (p=0.012) were the only predictors of favourable clinical outcome. CONCLUSIONS: Acute stroke attributable to carotid T occlusion remains a condition with a generally poor prognosis even when intra-arterial thrombolysis is performed. Favourable outcome was seen only in patients with sufficient leptomeningeal collaterals.

Adult↗
PubMed2002

Magnetic resonance angiography with ultrashort echo times reduces the artefact of aneurysm clips.

We evaluated the ability of an ultrashort echo time (TE) three-dimensional (3D) time-of-flight (TOF) magnetic resonance angiography (MRA) sequence to reduce the metal artefact of intracranial aneurysm clips and to display adjacent cerebral arteries. In five patients (aged 8-72 years) treated with Elgiloy or Phynox aneurysm clips we prospectively performed a conventional (TE 6.0 ms) and a new ultrashort TE (TE 2.4 ms) 3D TOF MRA. We compared the diameter of the clip-induced susceptibility artefact and the detectability of flow in adjacent vessels. The mean artefact diameter was 22.3+/-6.4 mm (range 14-38 mm) with the ultrashort TE and 27.7+/-6.4 mm (range 19-45 mm) with the conventional MRA ( P<0.0001). This corresponded to a diameter reduction of 19.5+/-9.2%. More parts of adjacent vessels were detected, but with less intense flow signal. The aneurysm dome and neck remained within the area of signal loss and were therefore not displayed. Ultrashort TE MRA is a noninvasive and fast method for improving detection of vessels adjacent to clipped intracranial aneurysms, by reducing clip-induced susceptibility artefact. The method cannot, however, be used to show remnants of the aneurysm neck or sac as a result of imperfect clipping.

Adult↗
PubMed2002

Whole-brain functional magnetic resonance imaging of cerebral arteriovenous malformations involving the motor pathways.

To investigate cortical, basal ganglia and cerebellar activation in patients with arteriovenous malformations (AVMs) involving the motor pathways, we studied ten patients (six male, four female, mean age 30.3 years, range 7.4-44.1) by whole-brain functional magnetic resonance imaging (fMRI) in a 1.5-T scanner with the EPI-BOLD-technique. In seven cases multiple fMRI studies were available, acquired in the course of the multi-session endovascular interventional treatment. Self-paced right- and left-handed finger-tapping tasks were used to invoke activation. In six patients a super-selective amytal test (Wada test) was performed during diagnostic pre-interventional angiography studies. Abnormal cortical activation patterns, with activation of the primary sensorimotor area, the supplementary motor area and/or the cerebellum shifted to unphysiological locations, were found in four patients. In all cases, localization of the AVM could account for the changes from the normal. After endovascular procedures, fMRI demonstrated shifts in the activation pattern in three patients. In the six patients that had undergone fMRI studies and the Wada test, both methods yielded comparable results. The fact that AVMs are structural anomalies for which the brain can partly compensate ('plasticity') was underlined by these results. fMRI is a valuable tool in the pre-therapeutic evaluation and post-interventional follow-up of patients with cerebral AVMs in whom an operation or an endovascular procedure is planned.

Adolescent↗