Clinical Neuroscience

[Systemic thrombolysis after the administration of idarucizumab in acute ischemic stroke]

PÁSZTOR Máté1, BERECZKI Dániel1, SZAKÁCS ZOLTÁN1, MAY Zsolt1

JULY 30, 2017

Clinical Neuroscience - 2017;70(07-08)

DOI: https://doi.org/10.18071/isz.70.0284

[Introduction - Expanding indications have resulted in an increasing number of patients taking novel oral anticoagulants, posing a major treatment dilemma in acute ischemic stroke. Case presentation - We present a successful intravenous thrombolysis in a dabigatran-treated patient with acute ischemic stroke after the administration of idarucizumab. Discussion - According to current guidelines, systemic thrombolysis is contraindicated under treatment with novel oral anticoagulants (taken within 48 hours). In this scenario, idarucizumab offers a solution by reversing the anticoagulant effect of dabigatran. Conclusion - Although there have only been case reports published so far, the dabigatran-antidote idarucizumab seems to give new therapeutic opportunities in the treatment of acute ischemic stroke.]

AFFILIATIONS

  1. Magyar Honvédség Egészségügyi Központ, Neurológiai Osztály, Budapest

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Clinical Neuroscience

[Calcium ion is a common denominator in the pathophysiological processes of amyotrophic lateral sclerosis]

PATAI Roland, NÓGRÁDI Bernát, MESZLÉNYI Valéria, OBÁL Izabella, ENGELHARDT József István, SIKLÓS László

[Amyotrophic lateral sclerosis (ALS), the most frequent motor neuron disease is characterized by progressive muscle weakness caused by the degeneration of the motor neurons in the spinal cord and motor cortex. However, according to the recent observations, ALS is a rather complex syndrome which frequently involves symptoms of cognitive impairment. Therefore, ALS cases can be interpreted in a clinico-pathological spectrum spanning from the classical ALS involving only the motor system to the fronto-temporal dementia. The progression of the disease, however, manifested in the degeneration of the upper and lower motor neurons, is based on the same complex pathobiology. The main elements of the pathomechanism, such as oxidative stress, excitotoxicity, immune/inflammatory processes and mitochondrial dysfunction are well described already, which operate in orchestrated way and amplify the deleterious effect of each other. It is assumed that calcium ions act as a catalyst in this interaction, hence each of the individual mechanisms has strong, positive and reciprocal calcium dependence thus may combine the individual pathological processes into a unified escalating mechanism of neuronal destruction. This review provides an overview of the role of calcium in connecting and amplifying the major mechanisms which lead to degeneration of the motor neurons in ALS. ]

Clinical Neuroscience

Validation of the Hungarian version of the Test Your Memory

KOLOZSVÁRI Róbert László, KOVÁCS György Zoltán, SZŐLLŐSI József Gergő, HARSÁNYI Szilvia, FRECSKA Ede, ÉGERHÁZI Anikó

Concerns regarding the projected prevalence of Alzheimer’s disease (AD) over the next several decades have stimulated a need for the detection of AD in its earliest stages. A self-administered cognitive test (Test Your Memory, TYM) is designed as a short, cognitive screening tool for the detection of AD. Our aim was to validate the Hungarian version of the Test Your Memory (TYM-HUN) test for the detection of AD. The TYM-HUN was applied in case of individuals aged 60 years or more, 50 patients with AD and 50 healthy controls were recruited into the study. We compared the diagnostic utility of the Hungarian version of the TYM in AD with that of the Mini-Mental State Examination (MMSE). The sensitivity and specificity of the TYM-HUN in the detection of Alzheimer’s disease were determined. The patients with AD scored an average of 15.5/30 on the MMSE and 20.3/50 on the TYM-HUN. The average score achieved by the members of the healthy control group was 27.3/30 on the MMSE and 42.7/50 on the TYM. The total TYM-HUN scores significantly correlated with the MMSE scores (Spearman’s rho, r=0.8830; p<0.001). Multivariate logistic regression model demonstrated that a one-point increase in the TYM score reduced the probability of having AD by 36%. The optimal cut-off score on the TYM-HUN was 35/36 along with 94% sensitivity and 94% specificity for the detection of AD. The TYM has a much wider scoring range than the MMSE and is also a suitable screening tool for memory problems, furthermore, it fulfils the requirements of being a short cognitive test for the non-specialists. The TYM-HUN is useful for the detection of Alzheimer’s disease and can be applied as a screening test in Hungarian memory clinics as well as in primary care settings.

Clinical Neuroscience

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BÜKI András, BARZÓ Pál, DEMETER Béla, KANIZSAI Péter, EZER Erzsébet, TÓTH Péter, HORVÁTH Péter, VARGA Csaba

[Traumatic brain injury (TBI) is recognized to be the main cause of death and disability in the first four decades representing a major socio-economical problem worldwide. Recent communications revealed a particularly worrying image about the quality of care for TBI in Hungary. For any improvement a systematic approach characterized by utilization of scientific evidence based guidelines forming the basis for close monitoring of the actual care are considered a prerequisite. In Hungary the first evidence based guidelines in the field of TBI have been issued by the National Society for Anesthesiology and Intensive Care more than two decades ago followed by joint guidelines of the Hungarian Neurosurgical Society and the Hungarian College of Neurosurgeons. These publications were primarily based on the work of the European Brain Injury Consortium as well as guidelines issued by the Brain Trauma Foundation. Recent renewal of the latter and a need to refresh the outdated national guidelines was met by a call from regulatory authorities to issue the updated version of the Hungarian TBI-guidelines. The present review is aimed to briefly summarize the most fundamental elements of the national head injury guidelines that would hopefully be officially issued in a far more detailed format soon.]

Clinical Neuroscience

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Clinical Neuroscience

[Is second-line immunomodulatory treatment effective in multiple sclerosis?]

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[Purpose - Natalizumab is the first evidence based monoclonal antibody, which was launched for treatment in relapsing remitting multiple sclerosis in Hungary in 2010. Standardized follow-up is required to use it. Our aim was to evaluate the efficacy and to monitor the safety of natalizumab treatment by using an electronic database established for MS registry. Clinical activity was measured by annual relapse rates, functional status of patients measured by EDSS and MFSC. Radiological activity was evaluated by standard MRI protocol. Data, results of MS patients and side effects of natalizumab treatment were recorded in iMed software. Results - 31 patients started the natalizumab treatment after 6.5±5.8 years from the onset of MS. The efficacy of treatment was evaluated after a mean of 67 (min: 14 max: 128) infusions in December 2016. The drop-out rate was low, due to the presence of neutralising antibodies in one case, pregnancy in two cases and development of malignant disease in one case which was not related to the natalizumab treatment. The treatment was well tolerated with excellent compliance without serious side effects. The annual relapse rate reduced from a mean of 1.7 to 0.03 (p<0.000001) in the first 12 months of treatment compared to the pretreatment 12 month activity, and it stayed at low level during the whole follow up. EDSS was stable or improved with an exception of two cases. In 23 subjects (77%) lack of new/enlarging T2 lesions and lack of gadolineum-enhancing lesions on MRI were observed. 18 patients (60%) had no evidence of disease activity (NEDA-3). PASAT test improved in most of the cases. Conclusion - The natalizumab therapy was very effective in all cases including those patients who had active disease under the previous immunomodulatory treatment.]

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Clinical Neuroscience

Risk factors for ischemic stroke and stroke subtypes in patients with chronic kidney disease

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Lege Artis Medicinae

[Perioperative management of patients taking new oral anticoagulants - dabigatran in focus]

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Clinical Neuroscience

Effects of CHADS2 score, echocardiographic and haematologic parameters on stroke severity and prognosis in patients with stroke due to nonvalvular atrial fibrillation

AYNACI Ozer, TEKATAS Aslan, AYNACI Gülden, KEHAYA Sezgin, UTKU Ufuk

Introduction - The aim of this study is to evaluate utility of CHADS2 score to estimate stroke severity and prognosis in patients with ischemic stroke due to non-valvular atrial fibrillation (AF) in addition to evaluate effects of hematologic and echocardiographic findings on stroke severity and prognosis. Methods - This prospective study included 156 ischemic stroke cases due to non-valvular AF in neurology ward of Trakya University Medical School between March 2013-March 2015. National Institute of Health Stroke (NIHS) score was used to evaluate severity of stroke at admission. Carotid and vertebral Doppler ultrasonography findings, brain computed tomography (CT) and magnetic resonance imaging (MRI) of the cases were evaluated. Left atrial diameter and ejection fraction (EF) values were measured. CHADS2 score was calculated. Modified Rankin Scale was used to rate the degree of dependence. Effects of age and sex of the patients, presence of diabetes mellitus (DM), Congestive Heart Failure (CHF), Cerebrovascular Disease (CVD) and C-reactive protein (CRP) levels on CHADS2, NIHS, and mRS were evaluated. Results - In patients with age ≥75, mean NIHS score was 3.3 points and mean mRS score was 1.02 points higher, than in patient below 75 years of age. Compared with the mild risk group, cases in the high risk group had older age, higher serum D-dimer, fibrinogen and CRP levels and lower EF. A positive relation was detected between stroke severity and Hemorrhagic Transformation (HT), previous CVD history, and presence of CHF. A significant association was found between increased stroke severity and Early Neurological Deterioration (END) development. Older age, higher serum fibrinogen, D-dimer, CRP and lower EF values were associated with poor prognosis. History of CVD and presence of CHF were associated with poor prognosis. END development was found to be associated with poor prognosis. In the high-risk group, 30.3% (n = 33) had END. Among those in the high-risk group according to the CHADS2 score, END development rate was found to be significantly higher than in the moderate risk group (p <0.05). There was a strong positive correlation between CHADS2 and NIHS scores. mRS score increased with increasing CHADS2 score and there was a strong correlation between them. Effect of stroke severity on prognosis was assessed and a positive correlation was found between NIHS score and mRS value. Discussion - Our study demonstrated the importance of CHADS2 score, haemostatic activation and echocardiographic findings to assess stroke severity and prognosis. Knowing factors which affect stroke severity and prognosis in patients with ischemic stroke may be directive to decide primary prevention and stroke management.

Clinical Neuroscience

[Effective, safe stroke prevention with novel oral anticoagulants in patients with atrial fibrillation. Focus on dabigatran]

SZAPÁRY László, FEHÉR Gergely, BOSNYÁK Edit, DELI Gabriella, CSÉCSEI Péter

[Non-valvular AF is the most common cardiac arrhytmia. Its incidence increases with age. AF is an independent risk factor for ischaemic stroke, representing a five times higher risk for it, associated with a high mortality rate. Beside AF, there are several other risk factors which influence the risk of stroke. Stroke risk calculator can be used to assess the risk of patient having a stroke. The most endangered group of patients with AF are those who have already suffered from cerebrovascular event. The only effective medication for prevention of stroke due to AF had been the application of vitamin K antagonists (VKA) which considerably decrease the rate of ischaemic event in a patient with AF providing that the INR is in the therapeutic range. VKA have several limitations of use in clinical practice and the fear of bleeding complications results an underusing of these drugs. Only 50% of all patients treated with VKA reaches the therapeutic range of INR. The breakthrough of prevention of stroke in recent years is undisputedly the coming out of novel oral anticoagulants (NOACs, thrombin and Xa-factor inhibitors). Recent studies suggest that these novel drugs prove the same efficacy as VKA drugs, furthermore dabigatran in a dose of 2×150 mg or apixaban in 2×5mg was statistically superior to warfarin in the prevention of stroke. NOACs have shown a large reduction in intracranial hemorrhage compared with warfarin. They are given as a fixed dose and do not require persistent monitoring making them much more convenient. NOACs at guidelines of European Society of Cardiology act as a preferable drugs in case of ischaemic stroke with AF. Probably the extended use of NOACs in clinical practice will be the mainstream of stroke prevention in the future.]

Clinical Neuroscience

[The importance of anticoagulant therapy in patients with artial fibrillation in stroke prevention – summary of international data and novel therapeutic modalities]

MIROLOVICS Ágnes, PAPP Csaba, ZSUGA Judit, BERECZKI Dániel

[The most common cardiogenic cause of ischaemic stroke is atrial fibrillation which increases the probability of stroke five-fold and doubles case fatality. Based on international data the incidence of atrial fibrillation is approx. 2% however this rapidly increases with age. The necessity of using oral anticoagulants in the prevention of non-valvular atrial fibrillation related stroke is decided based on estimated stroke risk. The CHADS2 and the more predictive CHA2DS2-VASc scales are used for this purpose while the bleeding risk of patients treated with anticoagulant may be estimated by the HAS-BLED scoring scale. For decades oral anticoagulation meant using vitamin-K antagonists. Based on international data we can see that rate of anticoagulation is unacceptably low, furthermore most of the anticoagulated patients aren’t within the therapeutic range of INR (INR: 2-3). A lot of disadvantages of vitamin-K antagonists are known (e.g. food-drug interaction, need for regular coagulation monitoring, increased risk of bleeding), therefore compounds with new therapeutic target have been developed. The novel oral anticoagulants (NOAC) can be divided in two major subgroups: direct thrombin inhibitors (dabigatran etexilate) and Xa-factor inhibitors (rivaroxaban, apixaban, edoxaban). These products are administered in fix doses, they less frequently interact with other medications or food, and regular coagulation monitoring is not needed when using these drugs. Moreover several studies have shown that they are at least as effective in the prevention of ischaemic stroke than the vitamin-K antagonists, with no more haemorrhagic complications.]