1. There is not the paragraph of introduction
2. You have to revise the manuscript for english language and you have to use the scientific medical terms in the case summary
3. Recently clinical study reported the benefits of CT angiography/CT perfusion imaging in cases of drug abuse like cocaine. This type of imaging differentiates multifocal vasospasm-induced hy- poperfusion/ischemia from focal thromboembolic ischemia/infarct, allowing for appropriate medical management in the crucial hyperacute time period (see Mehta SV, Gluncic V, Iqbal SM, Frank J, Ansari SA. Role of perfusion imaging in differentiating multifocal vasospasm-related ischemia versus thromboembolic stroke in a setting of cocaine abuse. J Stroke Cerebrovascular Diseases : Official J Natl Stroke Association. 2012; 21(8): 904 e3-6 and Siniscalchi A, Bonci A, Mercuri NB, De Siena A, De Sarro G, Malferrari G, Diana M, Gallelli L. Cocaine dependence and stroke: pathogenesis and management Curr Neurovasc Res. 2015;12(2):163-72). The authors need to discuss this point
4. There is insufficient evidence to evaluate the clinical utility of screening tests for drug abuse in primary care settings, including toxicology tests of blood or urine, or the use of standardized questionnaires to screen for drug use or misuse. However, it is reasonable to screen young patients, particularly men, for drug use when they present with cryptogenic stroke, please discuss and add this point in the discussion.
5. Caution should be exercised before using thrombolytic agents in patients drug abuse users due to the higher risk of intracranial bleeding (Siniscalchi A, Sztajzel R, Bonci A, Malferrari G, De Sarro G, Gallelli L. Editorial: Cocaine and Cerebral Small Vessel: Is it a Negative Factor for Intravenous Thrombolysis? Curr Vasc Pharmacol. 2016 Feb 4. [Epub ahead of print])
This is the article Drug abuse and failure of acute stroke intervention
Faisal Al-Abbas, Aisha Aldowaihi, Hala Abdulhadi, Hosam Al-Jehani
Acute stroke interventional therapy is becoming increasingly utilized in acute ischemic cerebrovascular accidents. This is boosted by the recent line of evidence via several well-conducted prospective randomized collectively showing a significant improvement in outcomes without a major therapy-induced morbidity or mortality.
With the significant and concerning increase in smoking and stroke risk factors in a relatively younger adults, the utilization of such effective therapies becomes of paramount importance.
Several factors have been described as to the reason for failure of acute stroke intervention. They could be patient related, clot related, or material related. We describe a patient in whom the failure of thrombectomy was related to drug abuse induced vasospasm resulting in middle cerebral artery occlusion.
32 year old otherwise healthy male presented to our emergency department at 10:00AM with acute onset of left sided weakness that started about an hour earlier. He was confused and had a smell of alcohol and was found to have dense hemipligea involving the face with a visual field cut. NIHSS was calculated as .16…. Denoting a large stroke. Code stroke was activated an the patient was found to have a right dense MCA sign on computerized tomography with no evidence of hemorrhage (figure). No contraindications to IV t-PA was found so the patient started receiving the bolts at 11:15 AM.
The patient was monitored for 30 minutes, and since there was no improvement in his deficits, he was shifted to the Angio suite around 12:00 PM.
The initial run of the right MCA showed M1 occlusion with no collateralized flow from ACA nor PCA. In addition, a wide-neck 3mm aneurysm was found in the Pcom with somewhat irregular wall. Accordingly, we deferred the use of IA-tPA in fear of hemorrhagic complications and the approach was for mechanical treatment. We deployed revive stent (Codman Jhinson and Johnson) through a 5F distal access catheter (Sophia). We perform 2 passes wth the stent retrieval, 7-minute each, yielding good size clots each time (figure). At this stage, we opted for mechanical distrubtion by the distal access catheter using wire disruption and suction. Consequently, a third and final pass with the stent retriever was done, with the distal tip of the stent well into the origin of M2. Clots were also retrieved but no recanalization was achieved. At this stage, we shifted our attention to the aneurysm, but as were preparing the patient became more confused and agitated, with unexplained hemodynamics instability for which he was incubated, and stabilized and shifts to the intensive care unit. A repeat CT was obtained showing no interval changes from the initial one. Shortly after arrival to the ICU, the toxicology screen revealed alcohol, cannabis and amphetamine intoxication. That was, at least in part, the explanation for the so the patient was started on milrinome as a vasodilator therapy for the vasospasm. The patient was started also on withdrawal measures by our psychiatry colleagues. He regained a grade 3/5 in his upper limb and 4/5 in his lower limb and was discharged to rehab as well as with close follow up with addiction medicine.
Acute ischemic stroke is a devastating life altering event. The approved use IV t-PA in 1995 revolutionized therapy(1), yet proved ineffective in the face of major vessel occlusion and some stubborn fibrin clots. The expanded time for IV t-PA and IA t-PA pushed the field forward. The introduction of interventional therapy with clot aspiration and mechanical disruption and most recently mechanical stent retrieval revolutionized ischemic stroke care.
This could not come at a better time as we face younger patients with ischemic strokes than previously perceived owing to more prevalence of stroke risk factors especially smoking among teenagers and young adults from both genders.
Substance abuse have been described for many years as a direct source of multitude of vascular deraingements affecting the proper functioning of the cerebrovascular units in defferant form might produce strokes by direct effects on the cerebral circulation, including elevated blood pressure, vasculitis, and cerebral vasospasm(2) (Table1)(3). This could lead to either ischemic or hemorrhagic strokes or both. In any type in manifests with, these patients pose a multi-tiered risk to the health care process.
The team needs to be notified as early as possible for contact precautions and sharps handling or invasive procedures performed on or around the patient. Specific substances require special regimens and could be reversed if known to improve the overall homeostasis of the patient. The after stroke care would potentially be complicated if the patient suffers a withdrawal and this becomes a delicate balance between the need for monitoring in a neurocritical care/stroke unit versus in a psychiatry ward in case the patients become agitated and combative posing risk of bodily harm to themselves, near by patients, and caring team.
Our patients was positive for alcohol, cannabis and amphetamine. These could have contributed to.presentation and progression The vasospasm observed on the angiogram could have potentially been treated with an intra-arterial vasodilator therapy in conjunction with mechanical thrombectomy. Further more, the procedure induced vasospasm could potentially be amileorated by using arterial dilators, although this is yet to be proven.
the identification of the intoxication promted a change of theraputic strategy towards the releive of vasospasm by the use of the MNH protocol(4) to booset the collaterals and minimize the size of the final infarction. that emphazise the need for maintining a reasonable index of suspecion in such patients to avoid missing their inciting factors in a way that will lead to significant potenitally reversible addd morbidity and in some case mortality.
comprehensive care model will dictate that an added layer of after care must be provided to these patients. After the acute care is concluded and besides the stroke secondary prevention protocols, these patients need significant and structured counselling in order to prevent another catastrophe in the future, affecting or ending the lives of these mostly young and productive members of society.in addition, vascular monitoring modalities are important such in our ptient in whom a 3 mm aneurysm is found “incidentally”. These should be monitored closly especially when the patient is at high risk for relapse or noncompliance with thesubstance abuse rehab.
in conclusion, Vasospasm induced MCA occlusion must be identified in a timly fashion to provide procedural and peri-procedural adjuncts to stroke therpay that will improve their outcome of the acute event and improve their outlook into the future.
SO AS implication
1- Young adult presented e stroke symptom we need to rule out drug abuse clinically and laboratory.
2- Take in consideration of the systematic effect of drug abuse on management mainly the cardiopulmonary effect
3- Addimg on routine workup of these cases MRA and black vessel imaging for identify the thrombus, vasospasm and vasculitis
4- Bypass the iv-tpa and going direct for angiosuite for thrombectomy and vasospasm management
5- Consider general anesthesia and intubation for these procedure
6- Using vascular dilator (nimodipine) e saline for all cases