Publications by authors named "Ethem Murat Arsava"

84 Publications

Intracerebral hemorrhage volume estimation: Is modification of the ABC/2 formula necessary according to the hematoma shape?

Clin Neurol Neurosurg 2021 Jun 24;207:106779. Epub 2021 Jun 24.

HacettepeUniversity Hospitals, Neurology Department, Neurocritical Care and Stroke Units, Ankara, Turkey. Electronic address:

Objective: We studied the proposal to modify the ABC/2 formula to ABC/3 for irregular-shaped intracerebral hematoma (ICH) volume estimation.

Patients And Methods: The volume of 133 ICHs were estimated with Kwak's (simplified C; all slices with hemorrhage are considered equal), Kothari's (weighted C) and coronal (reformatted C; measuring C directly on coronal reformatted images) ABC/2 methods, and compared with computer-assisted planimetric measurements. The accuracy, precision and correlation of three ABC/2 methods and their ABC/3 modifications were determined in smooth (Barras' group 1 or 2) and irregular (Barras' group 3-5) shaped ICHs.

Results: As the hematoma size increases, the shape becomes irregular. In all hematomas, both smooth (n = 81) and irregular (n = 52) shaped, Kothari's ABC/2 formula provided the closest result to the planimetric measurement, with an underestimation of 1.77 mL, and 10.2% difference on average. Kothari's ABC/2 disclosed the best correlation (Lin's coefficient=0.9622) regardless of ICH shape. When simplified-ABC/2 method was modified as ABC/3, volume estimation accuracy increased (Correlation coefficient increased from 0.838 to 0.915) for irregular hematomas; however, despite this improvement the accuracy remained below the Kothari's ABC/2 (not ABC/3) method. Neither reformatted coronal ABC/2 nor its ABC/3 modification provided any advantage over ABC/x formulas with slice counting.

Conclusion: Kothari's ABC/2 method is a valid method for estimation of ICH volume for both regular and irregular shaped hematomas. Simplified (Kwak's) ABC/2 or coronal ABC/2, or their /3 counterparts do not provide additional advantage.
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http://dx.doi.org/10.1016/j.clineuro.2021.106779DOI Listing
June 2021

Stroke Mechanism in COVID-19 Infection: A Prospective Case-Control Study.

J Stroke Cerebrovasc Dis 2021 Aug 1;30(8):105919. Epub 2021 Jun 1.

Department of Neurology, Hacettepe University Hospitals Turkey.

Background: The characteristics and pathophysiological mechanisms involved in acute ischemic stroke in patients with COVID-19 infection have not been fully clarified. We prospectively studied the phenotypic and etiological features of acute stroke occurring in COVID-19 infection.

Patients & Methods: Within nine months starting from April-2020, the presence of COVID-19 infection was determined by thoracic CT and SARS-CoV-2 PCR in all acute stroke cases managed in a single tertiary center. Consecutive and prospective data on vascular risk factors/comorbidities, in-hospital quality metrics, discharge outcomes, etiological subclassification and blood markers of thrombosis / inflammation were compared in 44 COVID-19 positive cases (37 acute ischemic stroke, 5 TIA, 2 intracerebral hematoma) and 509 COVID-19 negative patients (355 ischemic, 105 TIA, 44 hematoma and 5 stroke mimic).

Results: COVID-19 positive patients had more severe strokes, delayed hospital admission, longer hospital stay, higher mortality rates, but had similar vascular risk factors/comorbidities frequency, thrombolysis/thrombectomy utilization rates, metrics, and stroke etiological subtype. They had significantly higher CRP, fibrinogen, ferritin, leukocyte count and lower lymphocyte count. No difference was detected in aPTT, INR, D-dimer, platelet, hemoglobin, homocysteine levels and ANA, anti-dsDNA antibody and ENA panel positivity rates. Anti-phospholipid antibodies have been studied in 70% of COVID-19 positive and all cryptogenic patients, but were never found positive. Tests for coagulation factor levels and hereditary thrombophilia did not show major thrombophilia in any of the stroke patients with COVID-19.

Conclusion: We documented that there is no significant difference in etiological spectrum in acute stroke patients with COVID-19 infection. In addition, cryptogenic stroke and antiphospholipid antibody positivity rates did not increase.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2021.105919DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8166511PMC
August 2021

Time in therapeutic range among warfarin users in Turkey: Are there enough data to set definitive criteria for reimbursement?

Turk Kardiyol Dern Ars 2021 Jun;49(4):254-256

Units of Neuro Critical Care - Stroke, Department of Neurology, Hacettepe University School of Medicine, Ankara, Turkey.

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http://dx.doi.org/10.5543/tkda.2021.94055DOI Listing
June 2021

Alarms in a neurocritical care unit: a prospective study.

J Clin Monit Comput 2021 May 27. Epub 2021 May 27.

Faculty of Medicine, Neurology Department, Hacettepe University Hospitals, Neurointensive Care Unit, Sıhhiye, 06230, Ankara, Turkey.

The contemporary practice of monitoring physiologic parameters in the critical care setting is based on alarm systems with high sensitivity but low specificity. A natural consequence of this approach is a massive amount of alarms, which potentially leads to fatigue in the personnel and negatively impacts the quality of care provided. The study objective is to determine the prevalence, types, and determinants of alarms in a neurological critical care unit (NCCU) prototype. During a one-month period corresponding to 272 days of monitoring in 34 patients, nursing staff recorded the type and number of sounding alarms in a university NCCU. Alarms were categorized into three types as type-A alarms that were merely handled by the nursing staff, type-B alarms that were primarily managed by nurses, but the physician was also notified, and type-C alarms that were principally handled by NCCU physicians. There were a total of 9439 alarms, with an average of daily 34.7 alarms per bed, corresponding to one alarm every 41.4 min. Most of the alarms were type-A (57.7%), followed by type-B (39.2%) and type-C (3.1%) alarms. Alarms originated from electrocardiogram (34.6%), pulse oximeter (33.7%), noninvasive blood pressure monitoring (9.8%), respiratory monitoring (9.7%), intravenous fluid pumps (4.5%), ventilator (3.9%), enteral pumps (2.1%) and invasive blood pressure systems (1.7%). A noticeable diurnal variation was observed for type-A pulse oximeter, type-A and -B ECG alarms (increase during morning shifts), and type-A ventilator alarms (decrease during morning shifts). Alarms are highly prevalent in NCCUs and can correspond to an important portion of the workload.
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http://dx.doi.org/10.1007/s10877-021-00724-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8156574PMC
May 2021

The association between telomere length and ischemic stroke risk and phenotype.

Sci Rep 2021 May 26;11(1):10967. Epub 2021 May 26.

Department of Neurology, Faculty of Medicine, Hacettepe University, Sihhiye, 06100, Ankara, Turkey.

The chronological age of a person is a key determinant of etiology and prognosis in the setting of ischemic stroke. Telomere length, an indicator of biological aging, progressively shortens with every cell cycle. Herein, we determined telomere length from peripheral blood leukocytes by Southern blot analyses in a prospective cohort of ischemic stroke patients (n = 163) and equal number of non-stroke controls and evaluated its association with various ischemic stroke features including etiology, severity, and outcome. A shorter telomere length (i.e. lowest quartile; ≤ 5.5 kb) was significantly associated with ischemic stroke (OR 2.95, 95% CI 1.70-5.13). This significant relationship persisted for all stroke etiologies, except for other rare causes of stroke. No significant association was present between admission lesion volume and telomere length; however, patients with shorter telomeres had higher admission National Institutes of Health Stroke Scale scores when adjusted for chronological age, risk factors, etiology, and infarct volume (p = 0.046). On the other hand, chronological age, but not telomere length, was associated with unfavorable outcome (modified Rankin scale > 2) and mortality at 90 days follow-up. The association between shorter telomere length and more severe clinical phenotype at the time of admission, might reflect reduced resilience of cerebral tissue to ischemia as part of biological aging.
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http://dx.doi.org/10.1038/s41598-021-90435-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8155040PMC
May 2021

Development of imaging-based risk scores for prediction of intracranial haemorrhage and ischaemic stroke in patients taking antithrombotic therapy after ischaemic stroke or transient ischaemic attack: a pooled analysis of individual patient data from cohort studies.

Lancet Neurol 2021 04 17;20(4):294-303. Epub 2021 Mar 17.

Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.

Background: Balancing the risks of recurrent ischaemic stroke and intracranial haemorrhage is important for patients treated with antithrombotic therapy after ischaemic stroke or transient ischaemic attack. However, existing predictive models offer insufficient performance, particularly for assessing the risk of intracranial haemorrhage. We aimed to develop new risk scores incorporating clinical variables and cerebral microbleeds, an MRI biomarker of intracranial haemorrhage and ischaemic stroke risk.

Methods: We did a pooled analysis of individual-patient data from the Microbleeds International Collaborative Network (MICON), which includes 38 hospital-based prospective cohort studies from 18 countries. All studies recruited participants with previous ischaemic stroke or transient ischaemic attack, acquired baseline MRI allowing quantification of cerebral microbleeds, and followed-up participants for ischaemic stroke and intracranial haemorrhage. Participants not taking antithrombotic drugs were excluded. We developed Cox regression models to predict the 5-year risks of intracranial haemorrhage and ischaemic stroke, selecting candidate predictors on biological relevance and simplifying models using backward elimination. We derived integer risk scores for clinical use. We assessed model performance in internal validation, adjusted for optimism using bootstrapping. The study is registered on PROSPERO, CRD42016036602.

Findings: The included studies recruited participants between Aug 28, 2001, and Feb 4, 2018. 15 766 participants had follow-up for intracranial haemorrhage, and 15 784 for ischaemic stroke. Over a median follow-up of 2 years, 184 intracranial haemorrhages and 1048 ischaemic strokes were reported. The risk models we developed included cerebral microbleed burden and simple clinical variables. Optimism-adjusted c indices were 0·73 (95% CI 0·69-0·77) with a calibration slope of 0·94 (0·81-1·06) for the intracranial haemorrhage model and 0·63 (0·62-0·65) with a calibration slope of 0·97 (0·87-1·07) for the ischaemic stroke model. There was good agreement between predicted and observed risk for both models.

Interpretation: The MICON risk scores, incorporating clinical variables and cerebral microbleeds, offer predictive value for the long-term risks of intracranial haemorrhage and ischaemic stroke in patients prescribed antithrombotic therapy for secondary stroke prevention; external validation is warranted.

Funding: British Heart Foundation and Stroke Association.
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http://dx.doi.org/10.1016/S1474-4422(21)00024-7DOI Listing
April 2021

Long-term follow-up outcomes in a real-world study cohort after percutaneous patent foramen ovale closure.

Turk Kardiyol Dern Ars 2021 01;49(1):29-39

Department of Cardiology, Hacettepe University Faculty of Medicine, Ankara, Turkey.

Objective: In recent years, percutaneous closure of a patent foramen ovale (PFO) has gained widespread use. This study is an evaluation of the safety and efficacy of the Figulla and Amplatzer devices for PFO closure, including long-term follow-up results.

Methods: A total of 305 patients (43.6% male; mean age: 43.25±10.98 years) who underwent percutaneous PFO closure between 2003 and 2019 were enrolled. The Risk of Paradoxical Embolism (RoPE) score was calculated to predict the recurrence risk of cerebrovascular events due to PFO. Transthoracic echocardiography was used during the procedure.

Results: The devices were successfully implanted in all patients. The in-hospital periprocedural complications recorded were atrial fibrillation in 1 patient (0.3%), supraventricular tachycardia in 1 patient (0.3%), and femoral hematoma in 3 patients (1%). The procedure time and fluoroscopy time was 21.92±2.93 minutes and 2.19±0.24 minutes, respectively. Recurrent ischemic stroke or transient ischemic attack (TIA) was observed in 7 (2.2%) patients during the median 85.77 months (25th-75th percentile: 10.21-108.00 months) follow-up. The RoPE score was significantly lower in patients with recurrent ischemic cerebral event (stroke or TIA) compared with asymptomatic patients (p<0.001). Kaplan-Meier curve analysis revealed that there was no significant difference between PFO device types (Amplatzer: 2.4% vs. Figulla: 3.3%) in terms of recurrent ischemic cerebral events during follow-up (log-rank; p=0.642).

Conclusion: Percutaneous PFO closure was safe, feasible, and effective. Our study confirmed the efficacy and safety of transthoracic echocardiogram guidance during percutaneous closure of PFO, which shortens the procedure time. A lower RoPE score was related to the recurrence risk of ischemic cerebrovascular events.
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http://dx.doi.org/10.5543/tkda.2020.06699DOI Listing
January 2021

Intracerebral hematoma expansion and intracranial internal carotid artery calcifications.

Clin Neurol Neurosurg 2021 01 12;200:106361. Epub 2020 Nov 12.

Hacettepe University School of Medicine Department of Neurology, Ankara, Turkey. Electronic address:

Background And Aims: Prediction of intracerebral hematoma expansion (IHE) is of critical importance during intracerebral hemorrhage (ICH) management. Given its suggested positive connection with cerebral microvascular disease status, intracranial internal carotid artery wall calcifications (ICAC) on admission computed tomography (CT) studies may contribute to prediction of IHE.

Method: Presence, burden and type [as per Kockelkoren's score] of ICAC were defined in admission CT and CT-angiography of 201 ICH patients [mean age: 70 ± 13 years, 44 % female]. A Kockelkoren's score of <7 indicated intimal calcification [iICAC], while ≥7 indicated non-intimal [or medial] ones [mICAC]. IHE criteria were absolute volume increase of ≥12.5cc or ≥6cc, and relative increase ≥33 % or ≥26 %.

Result: ICAC was diagnosed in 79.6 % of ICH patients. ICAC status was not independent indicator of milder IHE (≥6cc and ≥26 % IHE, both in 27 %). Presence of contralateral mICAC was found to be an independent predictor for higher grade IHE (expβ = 3.44, 95 %CI: 1.47-8.04, for IHE ≥ 12.5cc, diagnosed in 14.4 %; and expβ = 2.67, 95 %CI: 1.29-5.55, for IHE ≥ 33 %, diagnosed in 24 %). Mortality (31 %) was higher in those with ipsilateral any type ICAC (36 % in mICAC, 38 % in iICAC, 17 % in no ICAC, p = 0.017), but this was not independent predictor in logistic regression. Similarly, medial ICAC in both ipsilateral (47 % vs. 31 %, p = 0.037) and contralateral (47 % vs. 30 %, p = 0.017) sides was associated with poorer prognosis (42 %) on univariate, but not multivariate analysis.

Conclusion: Intracranial ICA calcification is highly prevalent in ICH. mICAC may be associated with risk of "high amount" acute hematoma expansion, hospital mortality and poor prognosis.
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http://dx.doi.org/10.1016/j.clineuro.2020.106361DOI Listing
January 2021

Resuscitation in COVID-19 patients: What do we know and what should we do?

Cardiol J 2020 ;27(5):656-657

Hacettepe University Hospitals, Neurology Department and Neuro-ICU, SIHHIYE, 06230 ANKARA, Turkey.

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http://dx.doi.org/10.5603/CJ.2020.0161DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8078966PMC
November 2020

Systemic Inflammation Indices in Patients With Acute Ischemic Stroke Treated With Intravenous Tissue Plasminogen Activator: Clinical Yield and Utility.

Angiology 2021 03 6;72(3):279-284. Epub 2020 Nov 6.

Department of Neurology and Neurological Intensive Care Unit, 64005Hacettepe University Hospitals, Sihhiye, Ankara, Turkey.

Inflammation indices derived from complete blood counts (CBCs) have been proposed to estimate benefit and risk of intravenous (IV) tissue plasminogen activator (tPA) in acute ischemic stroke. In 165 acute ischemic patients, the neutrophil-to-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio, and systemic immune-inflammation index (SII) were calculated before and 24 hours after IV tPA. The area under receiver operating characteristic (AUC-ROC) curves, and positive and negative likelihood ratios (+LR,-LR) were produced to measure their diagnostic accuracy and clinical utility for tPA effectiveness, hemorrhage risk and third-month prognosis. None of the indices obtained "before" IV-tPA was found to be useful in determining acute and long-term functional efficacy and bleeding risk. Lymphocyte decrease, neutrophil increase, and parallel NLR and SII increase at the 24th-hour were associated with poor functional outcome. However, their clinical utility was not sufficient due to absence of effective thresholds. NLR threshold >5.65 provided ROC-AUC 0.86, sensitivity 71.3%, specificity 65.7%, -LR 0, +LR 3.76, and SII threshold >1781 had ROC-AUC 0.802, sensitivity 58.7%, specificity 72.7%, -LR 0.11, +LR 4.52, corresponding to an acceptable clinical yield. Systemic immune-inflammation index and NLR, but not other CBC-derived inflammatory parameters, have moderate utility as marker of tPA-related symptomatic hemorrhage occurrence.
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http://dx.doi.org/10.1177/0003319720969997DOI Listing
March 2021

Characteristic imaging features of neurovascular involvement in primary Sneddon's syndrome: an analysis of 12 cases.

Neurol Sci 2021 Jun 13;42(6):2363-2369. Epub 2020 Oct 13.

Neurology Department, Hacettepe University Hospitals, 06100, Sıhhiye, Ankara, Turkey.

Objective: Sneddon's syndrome is a cerebrocutaneous non-inflammatory progressive distal arteriopathy, characterized by livedo racemosa, stroke, and neuropsychiatric symptoms. Our aim was to highlight the characteristic neuroimaging features of Sneddon's syndrome that might be helpful to clinicians in timely diagnosis of this entity.

Methods: Twelve patients (median age 49 years, 11 female) with primary Sneddon's syndrome, diagnosed in last 10 years, were analyzed from the perspective of magnetic resonance imaging (MRI) features. In addition, a novel pseudoangiomatosis score was defined for grading angiographic abnormalities (range: 0 to 6).

Results: Median interval from the onset of neurological symptoms to diagnosis was 6 years. Presentation was with acute stroke in 5, seizures in 3, dementia/speech problems in 2, seizures plus cognitive dysfunction in 1, and chronic progressive hemiparesis in 1. All patients had a typical lesion pattern on MRI. This included multiple (median 3) cortical-subcortical supratentorial and cerebellar non-territorial infarcts, accompanied by multifocal cerebral atrophy. Of note, large territorial infarcts due to cerebral parent artery occlusion, an embolic pattern with multi-territorial involvement on diffusion-weighted imaging, small vessel disease features like severe white matter involvement or lacunar infarcts, and cerebral hemorrhage in the absence of anticoagulation were not observed. MRI lesion severity was not correlated with angiographic arteriopathy severity, clinical stage, or presentation symptoms.

Conclusion: Sneddon's syndrome is characterized by highly typical clinico-radiological features. Brain MRI has diagnostic value. By knowing the characteristics of the syndrome, misdiagnosis and potentially harmful treatment can be prevented in this entity that might pose a diagnostic challenge.
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http://dx.doi.org/10.1007/s10072-020-04621-0DOI Listing
June 2021

Isolated Sulcal Effacement and Response to Intravenous Thrombolysis in Acute Ischemic Stroke.

J Stroke Cerebrovasc Dis 2020 Oct 29;29(10):105168. Epub 2020 Jul 29.

Hacettepe University Hospitals, Neurology Department, Stroke Unit, Ankara, Turkey. Electronic address:

Background And Purpose: Isolated Sulcal Effacement (ISE) is focal cortical swelling without obscuration of cortical gray-white junction. The available information on its role in acute stroke patients treated with intravenous (IV) tissue plasminogen activator (tPA) is limited.

Methods: ISE along with ASPECT and rLMC collateral score were determined in pre-treatment CT/CT angiography of 195 consecutive acute stroke patients treated with IV tPA "only". In addition, ISE-ASPECT score was created. Role of ISE on responsiveness to IV tPA, thrombolysis-associated hemorrhage and functional outcome were studied in 102 patients with CT-angiography-confirmed anterior system proximal vessel occlusion.

Results: ISE was observed in 12 patients (6.2% of all and 11.4% of those with occlusion of the carotid terminus, M1, or proximal M2) corresponding to excellent specificity (100%) but fair sensitivity (12%) for diagnosis of anterior cerebral circulation proximal artery occlusion. ISE ASPECT score was significantly correlated with rLMC score (p=0.023). Presence of ISE was linked to younger age, female gender, lower NIHSS, along with higher ASPECT and rLMC scores. Albeit not persisted after adjustment for collateral status and NIHSS, dramatic response to IV tPA along with excellent (23% vs. 8%, p<0.05), good (21% vs. 6%, p<0.05) and acceptable (19% vs. 4%, p<0.05) functional outcome were significantly higher in patients with ISE.

Conclusions: As a plain CT marker of sufficient collateral status and increased cerebral blood volume, ISE indicates a better response to IV tPA. However, it should be noted that this relatively rare CT finding is highly specific for cerebral large vessel occlusions amenable neurothrombectomy.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.105168DOI Listing
October 2020

Efficacy and Safety of Ketamine in Refractory/Super-refractory Nonconvulsive Status Epilepticus: Single-Center Experience.

Clin EEG Neurosci 2020 Aug 5:1550059420942677. Epub 2020 Aug 5.

Department of Adult Neurology, Hacettepe University Faculty of Medicine, Ankara, Turkey.

Refractory/super-refractory nonconvulsive status epilepticus (r/srNCSE) is an acute life-threatening neurocritical entity with significant morbidity. Failure to control SE in its earlier stages leads to multiple molecular alterations in the brain such as downregulation of GABA-A and upregulation of NMDA receptors. Recently ketamine, an NMDA receptor antagonist, has gained increased attention as a therapeutic choice in controlling refractory/super-refractory SE. We aimed to analyze the efficacy and safety profile of ketamine in our center. We retrospectively identified all the patients with nonconvulsive SE who received ketamine during their follow-up in our neurological intensive care unit between 2009 and 2019. Information about demographic, clinical, and laboratory findings; concurrent antiseizure and anesthetic medications; time of initiation, dose and duration of ketamine infusion; any adverse effects and finally prognosis were collected. The effect of day of ketamine initiation and duration of infusion on ketamine efficacy were analyzed statistically. Seven patients (4 males, 3 females; age: 44-86 years) were included in the study. Encephalitis was the most common etiology. Concurrent antiseizure medications varied between 2 and 5. Six patients received midazolam before/during ketamine infusion. Ketamine was initiated 2 to 7 days after the onset of EEG monitoring and lasted 3 to 24 days with a maximum infusion dose ranging between 1 to 5 mg/kg/h. It was definitely effective in 4 patients, and possibly effective in an additional patient. Earlier initiation was correlated with higher efficacy ( = .047). There was a trend toward higher efficacy with longer duration of infusion ( = .285). Overall prognosis was poor with 29% mortality rate. Temporary hepatic failure occurred in 1 patient. Ketamine appears to be a promising drug in r/srNCSE. Earlier and prolonged infusion, as well as combination with benzodiazepines may increase its efficacy. Adverse events are rarely observed.
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http://dx.doi.org/10.1177/1550059420942677DOI Listing
August 2020

Cerebral vasomotor reactivity in migraine: effect of patent foramen ovale and aerogenic microembolism.

Neurol Res 2020 Sep 4;42(9):795-804. Epub 2020 Jun 4.

Department of Neurology, Hacettepe University Hospitals , Ankara, Turkey.

Objective: The first data on the effect of presence of patent foramen ovale (PFO) with high-volume right-to-left shunt (RLS) on cerebral vasomotor reactivity (CVMR) in migraineurs are herein presented. In addition, the immediate effect of air microbubbles on CVMR has been determined.

Methods: Breath-holding index (BHI) and percent velocity decrease during hyperventilation (HPV) tests were performed before and after agitated saline injections in bilateral middle and posterior cerebral arteries (MCA and PCA) in 38 migraineurs (19 with aura) and 18 control subjects.

Results: Presence of PFO correlated with a significant decrease of MCA BHI (1.43 ± 0.39 vs 1.04 ± 0.67, p = 0.032) and marginal reduction of PCA BHI (1.25 ± 0.46 vs. 1.01 ± 0.39, p = 0.090) in migraineurs. After agitated saline injection, PCA BHI significantly decreased from 1.03 to 0.78 (p = 0.007) in patients with PFO, from 1.15 to 0.91 (p = 0.014) in those without PFO, and from 1.01 to 0.76 (p = 0.023) in subjects with migraine and PFO. No significant MCA BHI difference was noted soon after bubble injection.

Conclusions: The presence of high grade RLS is associated with reduced vasodilatory CVMR in migraineurs. Further decrease of CVMR of PCA upon aerogenic microemboli passage may support the mechanism of 'facilitation with subclinical cerebral ischemia caused by microembolism', hypothesis explaining the onset of migraine.

Abbreviations: BHI: Breath-holding index; BHT: Breath Holding Test; CVMR: Cerebral vasomotor reactivity; EDV: End-diastolic velocity; HIT-6: Headache Impact Test; HPV: Hyperventilation; MCA: Middle cerebral artery; MIDAS: migraine disability Assessment score; PCA: Posterior cerebral artery; PFO: Patent foramen ovale; PI: Pulsatility index; PSV: Peak systolic velocity; RLS: Right-to-left shunt; TCD: Transcranial Doppler; Vmean: Mean velocity.
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http://dx.doi.org/10.1080/01616412.2020.1775015DOI Listing
September 2020

Determinants of preventable stroke-Ankara ACROSS stroke preventability study.

J Stroke Cerebrovasc Dis 2020 Jul 30;29(7):104825. Epub 2020 Apr 30.

Department of Neurology, Faculty of Medicine, Hacettepe University, Sihhiye, 06100 Ankara, Turkey. Electronic address:

Background: Unhealthy lifestyle and inadequate control of vascular risk factors are the major contributors of stroke burden. Failure in achieving the target levels in control of these factors, not only designate missed opportunities contributing to the preventability of an incident stroke, but also set the post-stroke treatment goals in a case wise basis. In this study, we analyzed pre-event clinical features that play a role in stroke preventability, and determined the cumulative burden of risk factors that necessitate optimization following the ischemic insult.

Methods: Information about the pre-stroke optimal control of seven major modifiable risk factors (Life's Simple 7: hypertension, diabetes mellitus, hyperlipidemia, smoking, obesity, diet, and physical activity) was prospectively collected in ischemic stroke patients admitted to three tertiary academic centers in Ankara. Stroke preventability was evaluated by the overall number of factors requiring optimization with patients ≥4 risk factor conditions categorized as those suffering from a preventable stroke. Bivariate and multivariate analyzes were performed to uncover predictors of stroke preventability.

Results: Among 787 patients, 386 (49.0%) had ≥4 risk factor conditions requiring optimization. Preventable stroke was more common in younger patients, and patients with small artery occlusion. Multivariate analyses taking into account the pre-stroke antithrombotic treatment regimen, have highlighted age (OR: 0.99, 95%CI 0.98-1.00), female gender (1.59, 95%CI 1.17-2.16), coronary artery disease (1.54, 95%CI 1.10-2.14), small artery occlusion (1.90, 95%CI 1.13-3.18), and cardio-aortic embolism (0.53, 95%CI 0.35-0.82) as significant factors associated with preventability.

Conclusions: Approximately half of the ischemic stroke patients have preventable stroke from the perspective of risk factor control. Extra care should be given to strategies directed to risk factor control and lifestyle interventions in certain high-risk groups for the prevention of future complications.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.104825DOI Listing
July 2020

The determinants of neurological phenotypes during acute hypertensive crises - a preliminary study.

Neurol Res 2020 May 2;42(5):398-404. Epub 2020 Mar 2.

Department of Neurology, Hacettepe University, Ankara, Turkey.

: Acute blood pressure elevations lead to wide spectrum of neurologic manifestations, ranging from no overt neurologic symptoms to catastrophic events like ICH. Little is known regarding the determinants of this clinical variability. We determined clinical and imaging features of hypertensive crisis patients with normal neurological examination, ICH and posterior reversible encephalopathy syndrome (PRES).: Cranial MRI was performed in patients with hypertensive urgency or emergency but normal neurological examination. Their clinical characteristics, and imaging features regarding cerebral small vessel disease were compared to ICH and PRES patients.: Hypertensive ICH patients (n = 58) were older, less likely to have hyperlipidemia, less commonly used calcium channel blockers, and had higher burden of chronic cSVD features in comparison to hypertensive crisis patients with normal neurological findings (n = 51). Multivariate analyses revealed cSVD burden score (p = 0.003) to be related with ICH, while higher admission blood pressure levels (p < 0.001), hyperlipidemia (p = 0.006) and calcium channel blocker usage (p = 0.005) were more common in patients with normal neurological examination. The PRES (n = 9) group was comprised of younger patients with recent history of hypertension and low burden of cSVD.: Hypertensive surge is associated with ICH when cSVD burden is high, probably caused by microvascular dysfunction secondary to long-standing hypertension, while the episode causes no structural damage if this burden is less. Although our observations are exploratory, short term but severe hypertension manifests with PRES possibly due to the absence of adaptive changes.
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http://dx.doi.org/10.1080/01616412.2020.1735121DOI Listing
May 2020

The dynamics of hematoma surface regularity and hematoma expansion in acute intracerebral hemorrhage.

J Clin Neurosci 2020 Apr 20;74:160-163. Epub 2020 Feb 20.

Department of Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey. Electronic address:

The clarification of factors that contribute to hematoma expansion in the setting of intracerebral hemorrhage (ICH) and the relevant physical dynamics are implemental for development of management strategies. Herein, we assessed the interplay between hematoma expansion and surface regularity of intracerebral bleeds. To do so, hematoma contours were outlined on admission and follow-up computed tomography (CT) studies using semi-automated thresholding algorithms in 133 ICH patients. Hematoma volume, surface area and surface regularity [SR=6√πvolumesurfacearea, ranging from 0 (very irregular surface) to 1 (perfectly regular surface suggestive of 3D spherical structure)] were determined by 3D Slicer software (www.slicer.org). Hematoma growth was defined as ≥33% relative growth, or ≥ 6 mL absolute growth. Our results are as follows: The median (IQR) hematoma volume was 14.2 (6.0-34.9) mL on admission CT obtained 2.4 (1.5-4.4) hours after symptom onset; the mean ± SD SR value was calculated as 0.62 ± 0.14. Patients who underwent imaging at earlier time points were more likely to have higher SR (r = 0.18; p = 0.035). The median hematoma volume at follow-up, 35 (21-47) hours after the initial scan, was 19.7 (6.9-44.4) mL. The regularity index decreased significantly at this time point to 0.58 ± 0.13 (p < 0.001) and corresponding increase of surface irregularity was independent of change in hematoma volume. Baseline hematoma volume, INR, and time to initial imaging were significant predictors of hematoma expansion. In conclusion, our findings suggest that hematomas evolve into more irregular 3D shapes during follow-up. These observations are consistent with the 'domino' hypothesis put forward for ICH expansion.
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http://dx.doi.org/10.1016/j.jocn.2020.01.081DOI Listing
April 2020

The Effect of Clot Volume and Permeability on Response to Intravenous Tissue Plasminogen Activator in Acute Ischemic Stroke.

J Stroke Cerebrovasc Dis 2020 Feb 3;29(2):104541. Epub 2019 Dec 3.

Hacettepe University, Faculty of Medicine, Department of Neurology, Neurocritical Care Unit, Ankara. Electronic address:

Background And Aims: The characteristics of clot causing acute ischemic stroke, such as size, content, and location, are among the main determinants of response to intravenous tissue plasminogen activator [IV tPA]. Clot heterogeneity and permeability are under-recognized features that might provide additional information in predicting the efficacy of IV tPA.

Methods And Patients: Patients with proximal middle cerebral artery occlusion treated with "IV tPA alone" were included. The mean Hounsfield's unit (HU) value, as objective measure of clot attenuation, and its standard deviation (SD), as proposed measure of clot heterogeneity, were obtained. The difference in HU values between CT Angiography and CT was defined as "clot permeability", or "perviousness'. The size (length and volume-mm3) of pre-clot pouch and occluding clot along with ASPECT score and Maas' silvian and leptomeningeal collateral score were measured.

Results: The study included 84 cases (44 women, age: 68 ± 14 years, pretPA NIHSS: 16 ± 5). Patients with excellent response to tPA (31%) had lower thrombus volume (37.54 ± 32.37 versus 63.49 ± 37.36, P = .009) and heterogeneity (4.05 ± 1.49 versus 5.35 ± 2.34, P = .011), along with higher clot permeability (48 ± 35.48 to 31.32 ± 18.62, P = .006). However, significance of permeability did not survived in the regression analysis with adjustment for NIHSS (β:-.296, P = .003); clot volume (β:-.240, P = .014) and collateral status (β:.346, P < .001). In patients with good prognosis, clot volume was significantly lower (37.76 ± 30.08 versus 67.57 ± 37.83, P < .001), whereas permeability was significantly higher (43.97 ± 32.33 versus 31.13 ± 19.01, P = .026). However, this effect did not persist in the regression analysis after adjustment for NIHSS (β:-.399, P < .001), collateral status (β: .343, P < .001) and clot volume (β:-.297, P = .001). Clot permeability was significantly higher (45.78 ± 36.34 versus 33 ± 20.2, P = .045) and heterogeneity was lower (4.1 ± 1.55 to 5.27 ± 2.32, P = .028) in patients with dramatic response to tPA (27%). In patients responding positively to IV tPA (48%), clot permeability was numerically higher (39.85 ± 31.79 to 33.47 ± 19.28, P = .268), while clot volume (48.15 ± 34.5 to 62.07 ± 39.62, P = .093) was lower. Clot volume, permeability and heterogeneity did not show a significant difference in any (38.1%) or symptomatic (8.3%) bleeders after IV tPA. The chance of IV tPA to be beneficial increased in patients with clot volume lower than 45 mm, with an increased likelihood of this benefit to be observed within the first day after IV tPA. Our detailed explorative ROC analysis was not able to detect a volume threshold above which the positive effect of IV tPA disappeared.

Conclusion: Clot volume is critical for the effectiveness of IV tPA in acute ischemic stroke. Clot permeability and heterogeneity may modify its effect. CT technologies, which are readily available when evaluating a stroke patient in an emergency setting, provide us with useful parameters regarding the size, permeability and heterogeneity of the clot.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2019.104541DOI Listing
February 2020

Time to Detection of the First Seizure in Patients With Nonconvulsive Status Epilepticus in the Neurological Intensive Care Unit.

Clin EEG Neurosci 2020 Jan 19;51(1):70-73. Epub 2019 Sep 19.

Department of Adult Neurology, Hacettepe University Faculty of Medicine, Ankara, Turkey.

Video-EEG monitoring is often used to detect nonconvulsive status epilepticus (NCSE) in critical care patients. Short recording durations may fail to detect seizures. In this study, we investigated the time required to record the first ictal event, and whether it could be correlated with some clinical or EEG parameters. Video-EEG recordings of patients who were followed up in our neurological intensive care unit were evaluated retrospectively. The EEG recordings of patients with NCSE were reviewed to determine the timing of the first seizure occurrence. Demographic data and EEG findings were obtained from patient charts and EEG reports. Possible correlations between the presence of periodic discharges (PD), Glasgow Coma Scale (GCS) score and early seizure detection (defined as a seizure within the first hour of recording) were explored statistically. Out of 200 patients who underwent video-EEG monitoring, we identified 30 cases (15%; 18 male, 12 female; age 24-86 years; mean recording duration 99 hours) with NCSE. The first seizure was recorded within 0 to 1 hour in 22 patients (73%) and within 1 to 12 hours in 6 patients (22%). Interictal PDs were identified in 19 patients (63%). GCS score was ≤8 in 16 patients (53%). There was no correlation between early seizure detection and PDs (p=1.0) or GCS score ( = .22). In our study, >90% of the seizures were captured within 12 hours. This finding suggests that most of the NCSE cases can be identified even in centers with limited resources. The presence or absence of PDs or GCS score does not predict the timing of the first seizure.
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http://dx.doi.org/10.1177/1550059419876509DOI Listing
January 2020

Floating Aortic Thrombus: A Rare Cause of Acute Ischemic Stroke Necessitating Modification of Access Route for Thrombectomy.

J Stroke Cerebrovasc Dis 2019 Nov 21;28(11):104291. Epub 2019 Aug 21.

Department of Radiology, Hacettepe University Faculty of Medicine, Ankara, Turkey. Electronic address:

We report 2 patients with acute occlusion of middle cerebral artery successfully treated by mechanical thrombectomy performed via transbrachial access. Both patients had floating aortic arch thrombi precluding safe transfemoral access due to risk of further iatrogenic embolization. Moreover both patients were diagnosed with hypercoagulopathy secondary to lung malignancy (paraneoplastic etiology, Trousseau's syndrome) as the cause of both aortic thrombi and acute ischemic stroke. Mechanical thrombectomy in the setting of a floating aortic thrombus has been mentioned only once as part of general management of floating aortic thrombi in the whole body. To the best of our knowledge, it has never been described previously in the literature in the context of cerebral mechanical thrombectomy technique. However, the diagnosis of this entity bears clinical importance for it can modify the treatment approach. A modified transbrachial approach allowed us to treat both patients without neurologic complications and resulted in modified Rankin scores of 1 on follow-up. We advise that the cross-sectional imaging of acute stroke patients should include an evaluation of the aortic arch and should be scrutinized in detail especially in patients with possible hypercoagulable state. Flat panel computed tomography technology allowed us to obtain such an imaging study in the angiography suite.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2019.07.007DOI Listing
November 2019

Cerebral microbleeds and stroke risk after ischaemic stroke or transient ischaemic attack: a pooled analysis of individual patient data from cohort studies.

Lancet Neurol 2019 07 23;18(7):653-665. Epub 2019 May 23.

Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.

Background: Cerebral microbleeds are a neuroimaging biomarker of stroke risk. A crucial clinical question is whether cerebral microbleeds indicate patients with recent ischaemic stroke or transient ischaemic attack in whom the rate of future intracranial haemorrhage is likely to exceed that of recurrent ischaemic stroke when treated with antithrombotic drugs. We therefore aimed to establish whether a large burden of cerebral microbleeds or particular anatomical patterns of cerebral microbleeds can identify ischaemic stroke or transient ischaemic attack patients at higher absolute risk of intracranial haemorrhage than ischaemic stroke.

Methods: We did a pooled analysis of individual patient data from cohort studies in adults with recent ischaemic stroke or transient ischaemic attack. Cohorts were eligible for inclusion if they prospectively recruited adult participants with ischaemic stroke or transient ischaemic attack; included at least 50 participants; collected data on stroke events over at least 3 months follow-up; used an appropriate MRI sequence that is sensitive to magnetic susceptibility; and documented the number and anatomical distribution of cerebral microbleeds reliably using consensus criteria and validated scales. Our prespecified primary outcomes were a composite of any symptomatic intracranial haemorrhage or ischaemic stroke, symptomatic intracranial haemorrhage, and symptomatic ischaemic stroke. We registered this study with the PROSPERO international prospective register of systematic reviews, number CRD42016036602.

Findings: Between Jan 1, 1996, and Dec 1, 2018, we identified 344 studies. After exclusions for ineligibility or declined requests for inclusion, 20 322 patients from 38 cohorts (over 35 225 patient-years of follow-up; median 1·34 years [IQR 0·19-2·44]) were included in our analyses. The adjusted hazard ratio [aHR] comparing patients with cerebral microbleeds to those without was 1·35 (95% CI 1·20-1·50) for the composite outcome of intracranial haemorrhage and ischaemic stroke; 2·45 (1·82-3·29) for intracranial haemorrhage and 1·23 (1·08-1·40) for ischaemic stroke. The aHR increased with increasing cerebral microbleed burden for intracranial haemorrhage but this effect was less marked for ischaemic stroke (for five or more cerebral microbleeds, aHR 4·55 [95% CI 3·08-6·72] for intracranial haemorrhage vs 1·47 [1·19-1·80] for ischaemic stroke; for ten or more cerebral microbleeds, aHR 5·52 [3·36-9·05] vs 1·43 [1·07-1·91]; and for ≥20 cerebral microbleeds, aHR 8·61 [4·69-15·81] vs 1·86 [1·23-1·82]). However, irrespective of cerebral microbleed anatomical distribution or burden, the rate of ischaemic stroke exceeded that of intracranial haemorrhage (for ten or more cerebral microbleeds, 64 ischaemic strokes [95% CI 48-84] per 1000 patient-years vs 27 intracranial haemorrhages [17-41] per 1000 patient-years; and for ≥20 cerebral microbleeds, 73 ischaemic strokes [46-108] per 1000 patient-years vs 39 intracranial haemorrhages [21-67] per 1000 patient-years).

Interpretation: In patients with recent ischaemic stroke or transient ischaemic attack, cerebral microbleeds are associated with a greater relative hazard (aHR) for subsequent intracranial haemorrhage than for ischaemic stroke, but the absolute risk of ischaemic stroke is higher than that of intracranial haemorrhage, regardless of cerebral microbleed presence, antomical distribution, or burden.

Funding: British Heart Foundation and UK Stroke Association.
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http://dx.doi.org/10.1016/S1474-4422(19)30197-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6562236PMC
July 2019

Reduced Ischemic Lesion Growth with Heparin in Acute Ischemic Stroke.

J Stroke Cerebrovasc Dis 2019 Jun 29;28(6):1500-1508. Epub 2019 Mar 29.

Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts. Electronic address:

Objective: The role of heparin in acute ischemic stroke is controversial. We investigated the effect of heparin on ischemic lesion growth.

Methods: Data were analyzed on nonthrombolyzed ischemic stroke patients in whom diffusion-weighted imaging (DWI)/perfusion-weighted imaging (PWI) MRI was performed less than 12 hours of last known well and showed a PWI-DWI lesion mismatch, and who underwent follow-up neuroimaging at least 4 days after admission. Lesion growth was assessed by (1) absolute lesion growth and (2) percentage mismatch lost (PML). Univariate and multivariate regression analysis, and propensity score matching, were used to determine the effects of heparin on ischemic lesion growth.

Results: Of the 113 patients meeting study criteria, 59 received heparin within 24 hours. Heparin use was associated with ∼5-fold reductions in PML (3.5% versus 19.2%, P = .002) and absolute lesion growth (4.7 versus 20.5 mL, P = .009). In multivariate regression models, heparin independently predicted reduced PML (P = .04) and absolute lesion growth (P = .04) in the entire cohort, and in multiple subgroups (patients with and without proximal artery occlusion; DWI volume greater than 5 mL; cardio-embolic mechanism; DEFUSE-3 target mismatch). In propensity score matching analysis where patients were matched by admission NIHSS, DWI volume and proximal artery occlusion, heparin remained an independent predictor of PML (P = .048) and tended to predict absolute lesion growth (P = .06). Heparin treatment did not predict functional outcome at discharge or 90 days.

Conclusion: Early heparin treatment in acute ischemic stroke patients with PWI-DWI mismatch attenuates ischemic lesion growth. Clinical trials with careful patient selection are warranted to investigate the potential ischemic protective effects of heparin.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2019.03.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6544494PMC
June 2019

The Fragility Index in Randomized Controlled Trials for Patent Foramen Ovale Closure in Cryptogenic Stroke.

J Stroke Cerebrovasc Dis 2019 Jun 16;28(6):1636-1639. Epub 2019 Mar 16.

Department of Neurology and Stroke Unit, Hacettepe University Hospitals, Sihhiye, Ankara, Turkey.

Background And Purpose: The routine use of percutaneous transcatheter patent foramen ovale closure (PPFOC) to prevent recurrent stroke in patients with cryptogenic stroke is still a matter of debate after completion major randomized controlled trials (RCTs).

Methods: The fragility index of RCTs evaluating effect of PPFOC against medial therapy alone in stroke prevention was calculated to assess the robustness of statistically significant findings.

Results: Literature search with PubMed identifies 6 RCTs on PPFOC. Median number of patients who underwent PPFOC and medical treatment were 340 and 229, respectively. Median number of the patients lost to follow-up was 20 in PPFOC and 18 in medical group. Fragility index was 0 for 4 studies. Median fragility index was also 0 for both "stroke" (interquartile range: 0-5.3) and "combined stroke and TIA" (interquartile range: 0-2) endpoints. In all studies except CLOSE, fragility index was smaller than or equal to the number of the subjects lost to follow-up.

Conclusions: Recent positive results of PFO closure studies should be interpreted cautiously because of their fragile characteristics. Routine PFO closure should be reserved for prevention of recurrence when suspicion for paradoxical embolism is high. Detailed individualized decision-making is crucial before ordering PPFOC for stroke prevention in patients with cryptogenic embolism.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2019.02.029DOI Listing
June 2019

Transvenous Treatment of Carotid Aneurysms Through Transseptal Access.

World Neurosurg 2019 Jan 17. Epub 2019 Jan 17.

Department of Neurology, Hacettepe University Hospitals, HUTF Noroloji ABD, Ankara, Turkey.

Background: Transseptal puncture has been widely used by cardiologists to reach the left side of the heart through a transvenous access. Rarely, it also can be used to pass into the supra-aortic arteries from the venous side when conventional transarterial access pathways (transfemoral, transradial/brachial routes, or direct carotid puncture) are likely to fail.

Case Description: We report 2 cases of transvenous femoral access followed by transseptal access to aorta to treat dissecting carotid artery aneurysms at the level of the skull base with flow diverters. In one case, multiple cervical arterial bypass operations and in the other a rare anomaly of the aortic arch precluded endovascular treatment through conventional routes.

Conclusions: Transvenous-transseptal access enabled treatment of both cases easily and without complications. On follow-up computed tomography angiograms, both flow diverters were patent, there were no residual aneurysms, and no neurologic or cardiac adverse events in either patient.
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http://dx.doi.org/10.1016/j.wneu.2018.12.207DOI Listing
January 2019

Occipital petalia as a predictive imaging sign for transverse sinus dominance.

Neurol Res 2019 Apr 2;41(4):306-311. Epub 2019 Jan 2.

a Department of Neurology, Faculty of Medicine , Hacettepe University , Ankara , Turkey.

Objectives: Occipital petalia is an anatomic description where one of the occipital lobes protrudes towards the contralateral side. Transverse sinus (TS) asymmetry might cause diagnostic challenges with regards to thrombotic or compressive pathologies involving these sinuses. In this study, we investigated the association between occipital petalia and TS hypoplasia on MRI studies.

Methods: In 264 subjects with no neurological complaints, occipital bending was determined on T1-weighted images based on the angulation of interhemispheric fissure between occipital lobes with respect to an imaginary midline. TS asymmetry was evaluated visually. Information on handedness and ocular dominance was also gathered from all participants.

Results: Rightwards bending was observed in 72 subjects (27%), whereas leftwards bending was present in only 10 participants (4%). The presence or direction of bending was related neither to hand nor ocular dominance. In participants with rightwards bending, 72% had a larger TS on the right-side, while only a single subject had a left-sided predilection for venous drainage. In subjects with leftwards bending, 70% had a left-dominant TS drainage system and none had a larger TS on the right. Overall, the direction of bending was predictive of TS dominance on the ipsilateral side with a PPV of 72% (95%CI, 60-82%) for right and 70% (95%CI, 35-92%) for left.

Discussion: The direction of bending, a relatively straightforward radiologic diagnosis, is closely linked to the side of TS hypoplasia, and thereby might provide physicians with an additional diagnostic clue regarding the interpretation of imaging findings related to TSs and their pathologies.
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http://dx.doi.org/10.1080/01616412.2018.1560643DOI Listing
April 2019

Cognitive Dysfunction in Relation to Topography and Burden of Cerebral Microbleeds.

Noro Psikiyatr Ars 2018 Mar 19;55(1):84-90. Epub 2018 Mar 19.

Department of Neurology, Hacettepe University Medical School Hospital, Ankara, Turkey.

Introduction: Contribution of cerebral microbleeds (CMBs) on cognitive dysfunctions in elderly patients with otherwise asymptomatic white matter lesions (WMLs) is not well-documented.

Methods: MRI parameters of cerebral atrophy, CMBs and WMLs were herein analyzed in relation to global and main domains (attention, executive, memory, visuospatial, language) of cognitive function. Eighty-five patients older than 50, without neurodegenerative/cerebrovascular disease, but had CMBs were recruited from 2562 with T2*-gradient-echo MR imaging during one-year period.

Results: Global cognition, evaluated by mini-mental status examination (MMSE), was impaired (score ≤24) in 42%. In contrast to CMBs load, WML burden and temporal atrophy were significantly higher in cases with MMSE≤24. Cholinergic Pathways HyperIntensities Scale (CHIPS) was positively correlated with global cognitive dysfunction but its CMB counterpart, Cholinergic Pathways Bleeding Scale described herein, was not. However, burden of CMBs in thalamic/cortical regions predicted language dysfunction.

Conclusion: Cognitive dysfunction associated with CMBs may be dependent on their distribution rather than their absolute number.
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http://dx.doi.org/10.29399/npa.23018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6045798PMC
March 2018

Neuroinvasive Listeriosis: Could Petechial Hemorrhages be a Diagnostic Clue?

Neurologist 2018 May;23(3):86-91

Departments of Neurology.

Introduction: Listeria monocytogenes-related central nervous system infections may involve the cerebral parenchyma. Meningitis and meningoencephalitis are the most commonly seen forms and mainly affect immunocompromised patients; however, a less frequent form, rhombencephalitis, can occur in otherwise healthy people. Early treatment with appropriate antibiotic therapy is crucial for this otherwise fatal disorder. However, it is not always possible to rapidly establish the diagnosis because of varying presentations and discrepancies in diagnostic tests.

Case Report: Herein we report 3 cases of listerial infections involving the central nervous system parenchyma, with versatile diagnostic challenges and related possible solutions and radiologic hints to overcome similar issues in the future.

Conclusions: We point out the importance of nonconventional magnetic resonance imaging techniques in the diagnosis, as we detected petechial hemorrhages in the brain parenchyma in all cases, which can be a diagnostic clue.
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http://dx.doi.org/10.1097/NRL.0000000000000170DOI Listing
May 2018

Atherosclerotic intracranial internal carotid artery calcification and intravenous thrombolytic therapy for acute ischemic stroke.

Atherosclerosis 2018 03 31;270:89-94. Epub 2018 Jan 31.

Department of Neurology and Neurological Intensive Care Unit, Hacettepe University Hospitals, Sihhiye, Ankara, Turkey. Electronic address:

Background And Aims: Intracranial internal carotid artery calcification (IICAC) is a frequent and readily available finding in acute stroke patients treated with intravenous (IV) tissue plasminogen activator (tPA). We aimed to investigate the effects of IICAC subtype (medial and intimal) on the response to IV tPA.

Methods: In this retrospective study, 91 (57% female, age 69 ± 13 years) consecutive acute anterior circulation stroke patients treated with IV tPA were included. IICAC were diagnosed and classified according to Kockelkoren's methods.

Results: IV tPA was effective at 24 h in 48% of patients with no IICAC (n = 27), 60% of intimal IICAC (n = 50) and 43% of medial IICAC (n = 14) (p=0.408). Presence of medial IICAC tended to be linked negatively to early dramatic response to IV tPA (p=0.052). IICAC status had no significant effect on the third month good (mRS≤2; 48% in no IICAC, 36% in intimal IICAC and 29% in medial IICAC; p=0.189) and favorable outcome (mRS≤1; 56% in no IICAC, 48% in intimal IICAC, 43% in medial IICAC, p=0.411). Frequency of symptomatic post-tPA cerebral hemorrhage was marginally higher in patients with non-intimal IICAC (21% vs. 4% in no-IICAC, 4% in intimal-IICAC, p=0.052). Exploratory multivariate analysis documented that this effect was stable (p=0.004) after adjustment for age, admission NIHSS and door-to-needle time.

Conclusions: Medial type IICAC has been associated with numerical increase of symptomatic intracerebral hemorrhage and decrease of early dramatic response in stroke patients receiving IV tPA. Acknowledging that these preliminary observations should be replicated in larger cohorts, it is currently reasonable to say that "the treatment" is still useful in these patients and the presence of medial IICAC does not justify withholding IV tPA.
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http://dx.doi.org/10.1016/j.atherosclerosis.2018.01.035DOI Listing
March 2018

Dual Mechanical Thrombectomy for Recanalization of a Resistant Acute Posterior Circulation Stroke.

J Cerebrovasc Endovasc Neurosurg 2017 Jun 30;19(2):96-100. Epub 2017 Jun 30.

Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey.

A 71-year-old man with acute basilar artery occlusion was referred for endovascular treatment 6 hours after the onset of stroke with a Glasgow Coma Score of 3 and National Institutes of Health Stroke Scale of 27. A cerebral arteriogram revealed occlusion of the left vertebral artery proximally and thromboembolic occlusion of the basilar tip. Direct aspiration and mechanical thrombectomy with various stent retrievers failed to reconstitute arterial flow in the basilar artery. Thrombolysis in cerebral infarction 2b recanalization was achieved only after placement of double Catch Mini stent retrievers through 2 microcatheters, on both side branches of the basilar bifurcation in a kissing fashion and retrieving them simultaneously. It was possible to perform this maneuver through a single distal access catheter without any complications. On follow-up the patient awakened and was able to follow commands on his right side. To our knowledge, dual mechanical thrombectomy with stent retrievers has not been reported in the posterior circulation previously. This technique may be useful in retrieving thrombi located at major intracranial bifurcations of the posterior circulation which do not recanalize with standard mechanical thrombectomy procedures. Although bilateral access to the basilar artery through both vertebral arteries is an advantage in posterior circulation for this technique, dual mechanical thrombectomy can also be performed through a unilateral access.
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http://dx.doi.org/10.7461/jcen.2017.19.2.96DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5678218PMC
June 2017

Do Video-EEG Monitoring Findings in ICU Patients With Acute Stroke Predict Development of Seizures and Survival During Follow-up?

Clin EEG Neurosci 2017 Nov 28;48(6):417-421. Epub 2017 Aug 28.

1 Hacettepe University Faculty of Medicine, Ankara, Turkey.

Purpose: Ischemic or hemorrhagic stroke are among the most common causes of seizures, especially in the elderly. EEG is the only technique that can detect epileptiform abnormalities (EA) and nonconvulsive status epilepticus (NCSE), which may negatively affect recovery of these patients. Herein we aimed to investigate the potential predictive value of long-term EEG findings in terms of poststroke seizures (PSS) and survival, in stroke patients followed up in the neurological intensive care unit (NICU).

Methods: Video-EEG reports of stroke patients (ischemic and hemorrhagic) hospitalized between 2009 and 2014 in our NICU were reviewed. Patients with <2 months of survival were excluded. Follow-up data were obtained via telephone calls or patient charts. The correlation between EEG findings and early (≤1 week) and late seizure (>1 week) occurrence, recurrent seizure development, outcome, and survival were analyzed statistically.

Results: Overall 50 patients (27 female, 23 male; age, 26-85 years) were included in the final analysis. Almost 60% developed PSS (~2/3 were early). There was no difference between ischemic versus hemorrhagic stroke patients ( P = .72). Recurrent seizures were more common in the late seizure group ( P < .001). EAs occurred in one-third of the study cohort. This finding did not predict seizure development ( P = .93) or survival ( P = .61).

Conclusion: PSS are a frequent finding in stroke patients followed up in NICU. EAs are not uncommon, but do not predict seizure occurrence or survival.
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http://dx.doi.org/10.1177/1550059417727225DOI Listing
November 2017