Biomedical subjects

Elizabeth A Noser

Publications and source records attributed to Elizabeth A Noser.

6 recordsLinked to original sources

PubMed2006

Is intra-arterial thrombolysis safe after full-dose intravenous recombinant tissue plasminogen activator for acute ischemic stroke?

BACKGROUND AND PURPOSE: The optimal approach for acute ischemic stroke patients who do not respond to intravenous recombinant tissue plasminogen activator (IV rt-PA) is uncertain. This study evaluated the safety and response to intra-arterial thrombolytics (IATs) in patients unresponsive to full-dose IV rt-PA. METHODS: A case series from a prospectively collected database on consecutive acute ischemic stroke patients treated with IATs after 0.9 mg/kg IV rt-PA during a 7-year interval was collected. Primary outcome measures included symptomatic intracranial hemorrhage and mortality. As indicators of response, secondary outcome measures were recanalization and discharge disposition. RESULTS: Sixty-nine patients (mean+/-SD age, 60+/-13 years; range, 26 to 85 years; 55% male) with a median pretreatment National Institutes of Health Stroke Scale score of 18 (range, 6 to 39) were included. IV rt-PA was started at 124+/-32 minutes (median, 120 minutes) and IAT, at 288+/-57 minutes (median, 285 minutes). IATs consisted of reteplase (n=56), alteplase (n=7), and urokinase (n=6), with an average total dosage of 2.8 U, 8.6 mg, and 700 000 U, respectively. Symptomatic intracranial hemorrhage occurred in 4 of 69 (5.8%) patients; 3 cases were fatal. Recanalization was achieved in 50 (72.5%) and a favorable outcome (home or inpatient rehabilitation) in 38 (55%). CONCLUSIONS: IAT therapy after full-dose IV rt-PA in patients with persisting occlusion and/or lack of clinical improvement appears safe compared with IV rt-PA alone or low-dose IV rt-PA followed by IAT. A high rate of recanalization and favorable outcome can be achieved.

Acute Disease↗

PubMed2004

Aggressive mechanical clot disruption: a safe adjunct to thrombolytic therapy in acute stroke?

BACKGROUND AND PURPOSE: This study evaluated the safety and efficacy of aggressive mechanical clot disruption (AMCD) in acute stroke patients with persisting middle cerebral artery (MCA) or internal carotid artery (ICA) occlusion after thrombolytic therapy. METHODS: Retrospective case series were used from a prospectively collected stroke database on consecutive acute ischemic stroke patients treated with intra-arterial (IA) thrombolytics and mechanical clot disruption during a 5-year interval. Thrombolytic dosage, endovascular techniques, immediate and final recanalization rates, symptomatic hemorrhage, mortality, and outcome were determined. RESULTS: Thirty-two patients received AMCD. Median baseline National Institutes of Health Stroke Scale (NIHSS) score was 18, and median time to initiation of IA treatment was 261 minutes from symptom onset. ICA occlusion was noted in 16 patients and MCA occlusion in 16 patients: 22 received combined IV/IA thrombolytics, 3 received IV thrombolytics, 6 received IA thrombolytics, and 1 patient received no thrombolytics before AMCD. No immediate periprocedural complications were noted. Immediate recanalization was achieved in 38% (50% MCA, 25% ICA) and final recanalization in 75% (88% MCA, 63% ICA) of patients. Favorable outcome occurred in 19 (59%) patients, symptomatic cerebral hemorrhage in 3 (9.4%) patients, and mortality in 4 (12.5%) patients. CONCLUSIONS: AMCD can be performed safely with comparable intracerebral hemorrhage and mortality rates to other IA therapies even after use of intravenous thrombolytics in selected patients. Early deployment of this technique leads to immediate recanalization in one third of patients. AMCD may potentially shorten the time to flow restoration and improve overall recanalization rates achieved with IA therapy.

Adult↗

PubMed2004

Yield and accuracy of urgent combined carotid/transcranial ultrasound testing in acute cerebral ischemia.

BACKGROUND AND PURPOSE: We routinely perform an urgent bedside neurovascular ultrasound examination (NVUE) with carotid/vertebral duplex and transcranial Doppler (TCD) in patients with acute cerebral ischemia. We aimed to determine the yield and accuracy of NVUE to identify lesions amenable for interventional treatment (LAITs). METHODS: NVUE was performed with portable carotid duplex and TCD using standardized fast-track (<15 minutes) insonation protocols. Digital subtraction angiography (DSA) was the gold standard for identifying LAIT. These lesions were defined as proximal intra- or extracranial occlusions, near-occlusions, > or =50% stenoses or thrombus in the symptomatic artery. RESULTS: One hundred and fifty patients (70 women, mean age 66+/-15 years) underwent NVUE at median 128 minutes after symptom onset. Fifty-four patients (36%) received intravenous or intra-arterial thrombolysis (median National Institutes of Health Stroke Scale (NIHSS) score 14, range 4 to 29; 81% had NIHSS > or =10 points). NVUE demonstrated LAITs in 98% of patients eligible for thrombolysis, 76% of acute stroke patients ineligible for thrombolysis (n=63), and 42% in patients with transient ischemic attack (n=33), P<0.001. Urgent DSA was performed in 30 patients on average 230 minutes after NVUE. Compared with DSA, NVUE predicted LAIT presence with 100% sensitivity and 100% specificity, although individual accuracy parameters for TCD and carotid duplex specific to occlusion location ranged 75% to 96% because of the presence of tandem lesions and 10% rate of no temporal windows. CONCLUSIONS: Bedside neurovascular ultrasound examination, combining carotid/vertebral duplex with TCD yields a substantial proportion of LAITs in excellent agreement with urgent DSA.

Acute Disease↗

PubMed2004

Constraint-induced movement therapy.

Constraint-induced movement therapy improves outcome after chronic stroke, conforms experimental observations of neuronal plasticity, and proves the efficacy of intensive occupational therapy. More acutely instituted constraint-induced movement therapy has both practical and theoretic risks and benefits that deserve further careful evaluation.

Animals↗

PubMedDate not supplied

Constraint-induced movement therapy during early stroke rehabilitation.

BACKGROUND: Limited data are available about the effectiveness of early rehabilitation after stroke. OBJECTIVE: This is the 1st randomized controlled trial of constraint-induced movement therapy (CIMT) in subacute stroke to investigate neurophysiologic mechanisms and long-term outcome. METHODS: Within 2 weeks after stroke, 23 patients with upper extremity (UE) weakness were randomized to 2 weeks of CIMT or traditional therapy at an equal frequency of up to 3 h/day. Motor function of the affected UE was blindly assessed before treatment, after treatment, and 3 months after stroke. Transcranial magnetic stimulation (TMS) measured the cortical area evoking movement of the affected hand. RESULTS: Long-term improvement in motor function of the affected UE did not differ significantly between patients who received CIMT versus intensive traditional therapy. All outcome comparisons showed trends favoring CIMT over intensive traditional therapy, but none was statistically significant except for improvements in the Fugl-Meyer (FM) UE motor scale immediately following treatment and in reported quality of hand function at 3 months. Improvement in UE motor function on the FM was associated with a greater number of sites on the affected cerebral hemisphere where responses of the affected hand were evoked by TMS. CONCLUSIONS: Future trials of CIMT during early stroke rehabilitation need greater statistical power, more inclusive eligibility criteria, and improved experimental control over treatment intensity. The relationship between changes in motor function and in evoked motor responses suggests that motor recovery during the 1st 3 months after stroke is associated with increased motor excitability of the affected cerebral hemisphere.

Adult↗

PubMedDate not supplied

Endovascular recanalization of internal carotid artery occlusion in acute ischemic stroke.

BACKGROUND: Endovascular therapy (ET) of internal carotid artery (ICA) stenosis is equivalent to carotid endarterectomy for stroke prevention; however, patients with ICA occlusion and acute symptoms are traditionally not candidates for ET. We report our experience in endovascular recanalization of acute stroke patients with ICA occlusion. PATIENTS AND TECHNIQUES: We reviewed our registry for acute stroke patients treated with ET who had (1) ICA occlusion by digital subtraction angiography (thrombolysis in myocardial ischemia=0) with location of type II (above ophthalmic artery involving M1 or A1 but not both) or type III (proximal to the ophthalmic artery but distal to the bifurcation); (2) acute stroke symptoms from the index lesion presenting 3 hours after onset of symptoms; (3) minimal ischemic changes on brain CT scan (less than one third of the MCA territory); (4) attempted ET. Neuroradiologists reviewed angiograms for thrombolysis in cerebral infarction. A blinded vascular neurologist reviewed post-procedural brain imaging for Alberta Stroke Program Early CT (ASPECT) scoring. Outcome scales were assessed. RESULTS: We identified 14 patients, 10 of whom were men (mean age, 58 +/- 14 years; median age, 54 years; age range, 40-74 years). There were 8 left ICA occlusions, 3 type II; and 6 right ICA occlusions, one type II. Median baseline National Institutes of Health Stroke Scale score was 17 (range, 11-25; mean, 18 +/- 4.9). Mean time to ET was 389 +/- 103 minutes (median, 306 minutes; range, 197-1290 minutes). Immediate recanalization occurred in 64%. Decrease in expected stroke volume by brain imaging occurred in 50% with mean ASPECT score of 4 +/- 2.9 (median, 3; range, 0-8; 21% > or = 8). Two hemorrhages occurred, one symptomatic; 3 patients died. Good outcome was achieved in 64% of cases. CONCLUSION: Endovascular therapy of carotid occlusion in hyperacute stroke patients is feasible and may help to reduce stroke volume and increase good outcome in some patients.

Adult↗