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Twedt, Max H., Benjamin D. Hage, James M. Hammel, et al. "Most High-Intensity Transient Signals Are Not Associated With Specific Surgical Maneuvers." World Journal for Pediatric and Congenital Heart Surgery 11, no. 4 (2020): 401–8. http://dx.doi.org/10.1177/2150135120909761.
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Background: Mortality after congenital heart defect surgery has dropped dramatically in the last few decades. Current research on long-term outcomes has focused on preventing secondary neurological sequelae, for which embolic burden is suspected. In children, little is known of the correlation between specific surgical maneuvers and embolic burden. Transcranial Doppler ultrasound is highly useful for detecting emboli but has not been widely used with infants and children. Methods: Bilateral middle cerebral artery blood flow was continuously monitored from sternal incision to chest closure in 20 infants undergoing congenital heart defect repair or palliative surgery. Embolus counts for specific maneuvers were recorded using widely accepted criteria for identifying emboli via high-intensity transient signals (HITS). Results: An average of only 13% of all HITS detected during an operation were correlated with any of the surgical maneuvers of interest. The highest mean number of HITS associated with a specific maneuver occurred during cross-clamp removal. Cross-clamp placement also had elevated HITS counts that significantly differed from other maneuvers. Conclusions: In this study of infants undergoing cardiac surgery with cardiopulmonary bypass, the great majority of HITS detected are not definitively associated with a specific subset of surgical maneuvers. Among the measured maneuvers, removal of the aortic cross-clamp was associated with the greatest occurrence of HITS. Future recommended research efforts include identifying and confirming other sources for emboli and longitudinal outcome studies to determine if limiting embolic burden affects long-term neurological outcomes.
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Mackie, Benjamin D., Farheen Shirazi, Matthew J. Swadley, Byron R. Williams, Gautam Kumar, and S. Tanveer Rab. "Catastrophic Systemic Embolization from a Left Atrial Myxoma." Texas Heart Institute Journal 41, no. 1 (2014): 64–66. http://dx.doi.org/10.14503/thij-12-2964.
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We report the fatal course of a left atrial myxoma: its systemic embolization to the coronary, cerebral, renal, and peripheral vascular beds in a 39-year-old woman resulted in rapid clinical deterioration, multiorgan failure, and death. Among reported cases of left atrial myxoma, this degree of embolic burden is exceedingly rare. In addition to reporting the patient's case, we discuss the presentation and diagnosis of possible intracardiac sources of systemic emboli.
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Heller, Robert S., Venkata Dandamudi, Michael Lanfranchi, and Adel M. Malek. "Effect of antiplatelet therapy on thromboembolism after flow diversion with the Pipeline Embolization Device." Journal of Neurosurgery 119, no. 6 (2013): 1603–10. http://dx.doi.org/10.3171/2013.7.jns122178.
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Object Flow-diverting stents offer a novel treatment approach to intracranial aneurysms. Data regarding the incidence of acute procedure-related thromboembolic complications following deployment of the Pipeline Embolization Device (PED) remain scant. The authors sought to determine the rate of embolic events in a bid to identify potential risk factors and assess the role of platelet inhibition. Methods Data in all patients receiving a PED for treatment of an intracranial aneurysm were prospectively maintained in a database. Diffusion-weighted 3-T MRI was performed within 24 hours of PED deployment. The incident rate of procedural embolism was established, and univariate analysis was then performed to determine any associations of embolic events with measured variables. The degree of platelet inhibition in response to aspirin and clopidogrel was evaluated by challenging the platelet samples with arachidonic acid and adenosine diphosphate, respectively, and then performing formal light transmission platelet aggregometry. Results Twenty-three patients with 26 aneurysms were eligible for inclusion in the study. Thirty-one PEDs were deployed in 25 procedures. All ischemic lesions detected on diffusion-weighted 3-T MRI were identified as embolic based on their location and distribution, with none appearing to be due to perforator artery occlusion. Procedural embolic events were found in the target parent vessel territory in 13 (52%) of 25 procedures, with no patients harboring lesions contralateral to the deployed PED. The number of embolic events per procedure ranged from 3 to 16, with a mean of 5.4. There was no significant difference between cases with and without procedural embolism in platelet inhibition by aspirin (mean 15% vs 12% residual activation; p = 0.28), platelet inhibition by clopidogrel (mean 41% vs 41% residual activation; p = 0.98), or intraprocedural heparin-induced anticoagulation (mean activated clotting time 235 seconds vs 237 seconds; p = 0.81). By multivariate analysis, the authors identified larger aneurysm size (p = 0.03) as the single variable significantly associated with procedural embolism. There was no significant relationship between aneurysm size and the number of embolic events (p = 0.32) or the total burden of the embolism lesion area (p = 0.53). Conclusions Acute embolism following use of the PED for treatment of intracranial aneurysms is more common than hypothesized. The only identifiable risk factor for embolism appears to be greater aneurysm size, perhaps indicating significant disturbed flow across the aneurysm neck with ingress and egress through the PED struts. The strength of antiplatelet therapy, as measured by residual platelet aggregation, did not appear to be associated with cases of procedural embolism. Further work is needed to determine the implications of these findings and whether anticoagulation regimens can be altered to lower the rate of complications following PED deployment.
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Malgor, Rafael D., Emily A. Wood, Otavio A. Iavarone, and Nicos Labropoulos. "Stratifying risk: asymptomatic carotid disease." Jornal Vascular Brasileiro 11, no. 1 (2012): 43–52. http://dx.doi.org/10.1590/s1677-54492012000100008.
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Stroke generates significant healthcare expenses and it is also a social and economic burden. The carotid artery atherosclerotic plaque instability is responsible for a third of all embolic strokes. The degree of stenosis has been deliberately used to justify carotid artery interventions in thousands of patients worldwide. However, the annual risk of stroke in asymptomatic carotid artery disease is low. Plaque morphology and its kinetics have gained ground to explain cerebrovascular and retinal embolic events. This review provides the readers with an insightful and critical analysis of the risk stratification of asymptomatic carotid artery disease in order to assist in selecting potential candidates for a carotid intervention.
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den Exter, P. L., L. J. M. Kroft, T. van der Hulle, F. A. Klok, D. Jiménez, and M. V. Huisman. "Embolic burden of incidental pulmonary embolism diagnosed on routinely performed contrast-enhanced computed tomography imaging in cancer patients." Journal of Thrombosis and Haemostasis 11, no. 8 (2013): 1620–22. http://dx.doi.org/10.1111/jth.12325.
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Duval, Cédric, Adomas Baranauskas, Tímea Feller та ін. "Elimination of fibrin γ-chain cross-linking by FXIIIa increases pulmonary embolism arising from murine inferior vena cava thrombi". Proceedings of the National Academy of Sciences 118, № 27 (2021): e2103226118. http://dx.doi.org/10.1073/pnas.2103226118.
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The onset of venous thromboembolism, including pulmonary embolism, represents a significant health burden affecting more than 1 million people annually worldwide. Current treatment options are based on anticoagulation, which is suboptimal for preventing further embolic events. In order to develop better treatments for thromboembolism, we sought to understand the structural and mechanical properties of blood clots and how this influences embolism in vivo. We developed a murine model in which fibrin γ-chain cross-linking by activated Factor XIII is eliminated (FGG3X) and applied methods to study thromboembolism at whole-body and organ levels. We show that FGG3X mice have a normal phenotype, with overall coagulation parameters and platelet aggregation and function largely unaffected, except for total inhibition of fibrin γ-chain cross-linking. Elimination of fibrin γ-chain cross-linking resulted in thrombi with reduced strength that were prone to fragmentation. Analysis of embolism in vivo using Xtreme optical imaging and light sheet microscopy demonstrated that the elimination of fibrin γ-chain cross-linking resulted in increased embolization without affecting clot size or lysis. Our findings point to a central previously unrecognized role for fibrin γ-chain cross-linking in clot stability. They also indirectly indicate mechanistic targets for the prevention of thrombosis through selective modulation of fibrin α-chain but not γ-chain cross-linking by activated Factor XIII to reduce thrombus size and burden, while maintaining clot stability and preventing embolism.
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Mayasi, Yunis, Johanna Helenius, David D. McManus, et al. "Atrial fibrillation is associated with anterior predominant white matter lesions in patients presenting with embolic stroke." Journal of Neurology, Neurosurgery & Psychiatry 89, no. 1 (2017): 6–13. http://dx.doi.org/10.1136/jnnp-2016-315457.
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ObjectiveHigh white matter hyperintensity (WMH) burden is commonly found on brain MRI among patients with atrial fibrillation (AF). However, whether the link between AF and WMH extends beyond a common vascular risk factor profile is uncertain. We sought to determine whether AF relates to a distinct WMH lesion pattern which may suggest specific underlying pathophysiological relationships.MethodsWe retrospectively analysed a cohort of consecutive patients presenting with embolic stroke at an academic hospital and tertiary referral centre between March 2010 and March 2014. In total, 234 patients (53% female, 74% anterior circulation infarction) fulfilled the inclusion criteria and were included in the analyses. WMH lesion distribution was classified according to previously defined categories. Multivariable logistic regression analysis was performed to determine variables associated with AF within 90 days of index hospital discharge.ResultsAmong included patients, 114 had AF (49%). After adjustment for the CHA2DS2-VASc score (congestive heart failure, hypertension, age ≥75 years (doubled), diabetes mellitus, prior stroke/TIA (doubled), vascular disease, age 65–74 years, sex category (female)) score, WMH lesion burden as assessed on the Fazekas scale, embolic stroke pattern, infarct distribution and pertinent interaction terms, AF was significantly associated with presence of anterior subcortical WMH patches (OR 3.647, 95% CI 1.681 to 7.911, p=0.001).ConclusionsAF is associated with specific WMH lesion pattern among patients with embolic stroke aetiology. This suggests that the link between AF and brain injury extends beyond thromboembolic complications to include a cardiovasculopathy that affects the brain and can be detected and characterised by WMH.
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Le Roux, Pierre-Yves, Kate Burbury, Michael S. Hofman, and Rodney J. Hicks. "Short and long-term prognostic implications of a low embolic burden in oncology patients diagnosed with symptomatic pulmonary embolism." Annals of Hematology 95, no. 4 (2016): 651–52. http://dx.doi.org/10.1007/s00277-016-2593-2.
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Boriani, Giuseppe, Marco Vitolo, Jacopo Francesco Imberti, Tatjana S. Potpara, and Gregory Y. H. Lip. "What do we do about atrial high rate episodes?" European Heart Journal Supplements 22, Supplement_O (2020): O42—O52. http://dx.doi.org/10.1093/eurheartj/suaa179.
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Abstract Atrial high rate episodes (AHREs) are defined as asymptomatic atrial tachyarrhythmias detected by cardiac implantable electronic devices with atrial sensing, providing automated continuous monitoring and tracings storage, occurring in subjects with no previous clinical atrial fibrillation (AF) and with no AF detected at conventional electrocardiogram recordings. AHREs are associated with an increased thrombo-embolic risk, which is not negligible, although lower than that of clinical AF. The thrombo-embolic risk increases with increasing burden of AHREs, and moreover, AHREs burden shows a dynamic pattern, with tendency to progression along with time, with potential transition to clinical AF. The clinical management of AHREs, in particular with regard to prophylactic treatment with oral anticoagulants (OACs), remains uncertain and heterogeneous. At present, in patients with confirmed AHREs, as a result of device tracing analysis, an integrated, individual and clinically-guided assessment should be applied, taking into account the patients’ risk of stroke (to be reassessed regularly) and the AHREs burden. The use of OACs, preferentially non-vitamin K antagonists OACs, may be justified in selected patients, such as those with longer AHREs durations (in the range of several hours or ≥24 h), with no doubts on AF diagnosis after device tracing analysis and with an estimated high/very high individual risk of stroke, accounting for the anticipated net clinical benefit, and informed patient’s preferences. Two randomized clinical trials on this topic are currently ongoing and are likely to better define the role of anticoagulant therapy in patients with AHREs.
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Knol, Wiebe G., Ad J. J. C. Bogers, Loes M. M. Braun, et al. "Aortic calcifications on routine preoperative chest X-ray and perioperative stroke during cardiac surgery: a nested matched case–control study." Interactive CardioVascular and Thoracic Surgery 30, no. 4 (2019): 507–14. http://dx.doi.org/10.1093/icvts/ivz295.
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Abstract OBJECTIVES Perioperative stroke in cardiac surgery is most often embolic in origin. Preoperative chest X-ray (CXR) is routinely used amongst others to screen for relevant aortic calcification, a potential source of embolic stroke. We performed a nested matched case–control study to examine the relationship between aortic calcifications on CXR and the occurrence of embolic stroke. METHODS Among all consecutive patients undergoing cardiac surgery in our hospital between January 2014 and July 2017, we selected all patients with perioperative embolic stroke (cases). Controls, all patients without perioperative stroke, were matched on age, sex and type of surgery. All preoperative CXRs were scored for aortic calcifications (none, mild, severe) in the ascending aorta, arch, aortic knob and descending aorta. RESULTS Out of the 3038 eligible patients, 27 cases were detected and 78 controls were selected. In the stroke group, mild-to-severe calcifications were found least often in the ascending aorta [9% of patients, 95% confidence interval (CI) 1–29%] and most frequently in the aortic knob (63% of patients, 95% CI 44–78%). The distribution of aortic calcification was comparable in cases versus controls. CONCLUSIONS Calcification burden was comparable between the cases and their matched controls. In our study population, CXR findings on aortic calcification were not related to the risk of embolic stroke. In these patients, the correlation between findings on the preoperative CXR and the risk of stroke might, therefore, be too weak to use the CXR directly for the assessment of the safety of manipulating the ascending aorta during surgery.
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Krca, Bojana, Boris Dzudovic, Snjezana Vukotic, et al. "Association of different electrocardiographic patterns with shock index, right ventricle systolic pressure and diameter, and embolic burden score in pulmonary embolism." Vojnosanitetski pregled 73, no. 10 (2016): 921–26. http://dx.doi.org/10.2298/vsp150512011k.
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Background/Aim. Some electrocardiographic (ECG) patterns are characteristic for pulmonary embolism but exact meaning of the different ECG signs are not well known. The aim of this study was to determine the association between four common ECG signs in pulmonary embolism [complete or incomplete right bundle branch block (RBBB), S-waves in the aVL lead, S1Q3T3 sign and negative T-waves in the precordial leads] with shock index (SI), right ventricle diastolic diameter (RVDD) and peak systolic pressure (RVSP) and embolic burden score (EBS). Methods. The presence of complete or incomplete RBBB, S waves in aVL lead, S1Q3T3 sign and negative T-waves in the precordial leads were determined at admission ECG in 130 consecutive patients admitted to the intensive care unit of a single tertiary medical center in a 5-year period. Echocardiography examination with measurement of RVDD and RVSP, multidetector computed tomography pulmonary angiography (MDCT-PA) with the calculation of EBS and SI was determined during the admission process. Multivariable regression models were calculated with ECG parameters as independent variables and the mentioned ultrasound, MDCT-PA parameters and SI as dependent variables. Results. The presence of S-waves in the aVL was the only independent predictor of RVDD (F = 39.430, p < 0.001; adjusted R2 = 0.231) and systolic peak right ventricle pressure (F = 29.903, p < 0.001; adjusted R2 = 0.185). Negative T-waves in precordial leads were the only independent predictor for EBS (F = 24.177, p < 0.001; R2 = 0.160). Complete or incomplete RBBB was the independent predictor of SI (F = 20.980, p < 0.001; adjusted R2 = 0.134). Conclusion. In patients with pulmonary embolism different ECG patterns at admission correlate with different clinical, ultrasound and MDCT-PA parameters. RBBB is associated with shock, Swave in the aVL is associated with right ventricle pressure and negative T-waves with the thrombus burden in the pulmonary tree.
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Shalnev, V. I. "A MODERN APPROACH TO THE TREATMENT AND PROPHYLAXIS OF VENOUS THROMBOEMBOLISM. PART II." EMERGENCY MEDICAL CARE 18, no. 4 (2018): 60–65. http://dx.doi.org/10.24884/2072-6716-2017-18-4-60-65.
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The article highlights the burden of the venous thromboembolism (VTE) in clinical practice as one of the most frequent cause of cardiovascular death and disabling embolic stroke worldwide. The author compares the traditional use of VKA antagonists and new class of oral anticoagulants — direct thrombin and factor Xa inhibitors for VTE treatment and prevention. The results of most significant randomized clinical trials in VTE area and latest international guidelines are also discussed.
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Neves, David, Pedro Silva Cunha, and Mário Oliveira. "Duração dos Episódios de Fibrilhação Auricular e Implicações no Risco Tromboembólico." Acta Médica Portuguesa 28, no. 6 (2015): 766. http://dx.doi.org/10.20344/amp.6359.
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<strong>Introduction:</strong> Atrial fibrillation is the most common chronic arrhythmia in clinical practice, which is associated with a well known increased thromboembolic risk. The use of oral anticoagulants in this context is well established. However, there are some gaps in information that warrant further studies, such as the duration of an atrial fibrillation event that is long enough to increase the risk of embolic phenomena. This may be of important clinical concern, particularly in patients with cardiac implanted devices, in which very short periods of asymptomatic atrial fibrillation are often detected.<br /><strong>Material and Methods:</strong> We performed a critical review on the association of brief atrial fibrillation episodes and thromboembolic events, based on available literature indexed on PubMed.<br /><strong>Results:</strong> After initial selection of abstracts and checking of references a final pool of 8 papers were analysed; seven describing studies with cardiac implanted devices and one with Holter monitoring. Four of the studies addressed this issue with a ‘daily burden’ approach rather than single episode duration. The risk increases with the magnitude of atrial fibrillation burden, with 5 minutes of atrial fibrillation in one day being the shortest time shown to independently predict thromboembolic events.<br /><strong>Discussion: </strong>The formation of an intracardiac thrombus, and respective embolic potential, is a dynamic process resulting from the interaction of anatomical and functional variables. The individual risk will depend on these factors. The association between embolic events and short atrial fibrillation episodes is evident, although the mechanism is not obvious, given the time discrepancy that is frequently observed between atrial fibrillation episode and clinical event.<br /><strong>Conclusions:</strong> An atrial fibrillation burden of 5 minutes in one day has been shown to be independently associated with a significantly increased risk, although the cause-effect mechanism is not clear. A standardized way to select patients with short-duration atrial fibrillation periods that will have a meaningful benefit of chronic oral anticoagulation is still to define. Therefore, decisions should be made in an individualized manner.
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Meyne, J., P. Zimmermann, A. Rohr, et al. "Thrombectomy vs. Systemic Thrombolysis in Acute Embolic Stroke with High Clot Burden: A Retrospective Analysis." RöFo - Fortschritte auf dem Gebiet der Röntgenstrahlen und der bildgebenden Verfahren 187, no. 07 (2015): 555–60. http://dx.doi.org/10.1055/s-0034-1399222.
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Shaya, Shana A., Dhulfiha Muzafar Gani, Jeffrey I. Weitz, Paul Y. Kim, and Peter L. Gross. "Factor XIII Prevents Pulmonary Emboli in Mice by Stabilizing Deep Vein Thrombi." Thrombosis and Haemostasis 119, no. 06 (2019): 992–99. http://dx.doi.org/10.1055/s-0039-1685141.
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Background Deep vein thrombosis (DVT) can lead to pulmonary embolism (PE), but the mechanisms responsible for this progression are unknown. Previously, we showed that inhibition of thrombin-mediated activation of factor (F) XIII promotes venous thrombus stability in a murine model. Aim In this study, we investigate the consequence of attenuating fibrinolysis, using FXIII, α2-antiplasmin (α2-AP) or ε-aminocaproic acid (EACA) supplementation, on clot lysis and venous thrombus stability using the same mouse model. Methods In vitro plasma clot lysis assay shows that EACA and α2-AP but not FXIII, inhibit fibrinolysis. Ferric chloride induced thrombi in the femoral vein of mice. After thrombus formation, mice received saline, EACA, α2-AP or FXIII, with or without dalteparin or dabigatran. Thrombus sizes and embolization over 2 hours were visualized using intravital videomicroscopy. Lungs were sectioned to quantify emboli presence via histology. Results The change in thrombus size over time was significantly greater after EACA treatment, but not FXIII or α2-AP supplementation, compared with saline. α2-AP-supplementation did not alter thrombus stability. Thrombi were more stable following EACA treatment and FXIII supplementation as evidenced by less embolic events and PE burden, even when they were anticoagulated with either dalteparin or dabigatran. Conclusion FXIII supplementation stabilized venous thrombi, even in the presence of anticoagulants, and did not alter thrombus size. Supplemental FXIII may be useful to stabilize DVT and be an alternative adjunctive treatment to minimize PE, even when anticoagulants are used.
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Vedovati, M. C., F. Germini, G. Agnelli, and C. Becattini. "Prognostic role of embolic burden assessed at computed tomography angiography in patients with acute pulmonary embolism: systematic review and meta-analysis." Journal of Thrombosis and Haemostasis 11, no. 12 (2013): 2092–102. http://dx.doi.org/10.1111/jth.12429.
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Hankey, G., T. Nafee, R. Welsh, and C. Gibson. "Beyond Stroke Prevention in Atrial Fibrillation: Exploring Further Unmet Needs with Rivaroxaban." Thrombosis and Haemostasis 118, S 01 (2018): S34—S44. http://dx.doi.org/10.1055/s-0038-1635086.
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AbstractWith improved life expectancy and the aging population, the global burden of atrial fibrillation (AF) continues to increase, and with AF comes an estimated fivefold increased risk of ischaemic stroke. Prophylactic anticoagulant therapy is more effective in reducing the risk of ischaemic stroke in AF patients than acetylsalicylic acid or dual-antiplatelet therapy combining ASA with clopidogrel. Non-vitamin K antagonist oral anticoagulants are the standard of care for stroke prevention in patients with non-valvular AF. The optimal anticoagulant strategy to prevent thromboembolism in AF patients who are undergoing percutaneous coronary intervention and stenting, those who have undergone successful transcatheter aortic valve replacement and those with embolic stroke of undetermined source are areas of ongoing research. This article provides an update on three randomized controlled trials of rivaroxaban, a direct, oral factor Xa inhibitor, that are complete or are ongoing, in these unmet areas of stroke prevention: oPen-label, randomized, controlled, multicentre study explorIng twO treatmeNt stratEgiEs of Rivaroxaban and a dose-adjusted oral vitamin K antagonist treatment strategy in patients with Atrial Fibrillation who undergo Percutaneous Coronary Intervention (PIONEER AF-PCI) trial; the New Approach riVaroxaban Inhibition of factor Xa in a Global trial vs Aspirin to prevenT Embolism in Embolic Stroke of Undetermined Source (NAVIGATE ESUS) trial and the Global study comparing a rivAroxaban-based antithrombotic strategy to an antipLatelet-based strategy after transcatheter aortIc vaLve rEplacement to Optimize clinical outcomes (GALILEO) trial. The data from these studies are anticipated to help address continuing challenges for a range of patients at risk of stroke.
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Wong, Gregory J., Bryan Yoo, David Liebeskind, et al. "Frequency, Determinants, and Outcomes of Emboli to Distal and New Territories Related to Mechanical Thrombectomy for Acute Ischemic Stroke." Stroke 52, no. 7 (2021): 2241–49. http://dx.doi.org/10.1161/strokeaha.120.033377.
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Background and Purpose: Clot fragmentation and distal embolization during endovascular thrombectomy for acute ischemic stroke may produce emboli downstream of the target occlusion or in previously uninvolved territories. Susceptibility-weighted magnetic resonance imaging can identify both emboli to distal territories (EDT) and new territories (ENT) as new susceptibility vessel signs (SVS). Diffusion-weighted imaging (DWI) can identify infarcts in new territories (INT). Methods: We studied consecutive acute ischemic stroke patients undergoing magnetic resonance imaging before and after thrombectomy. Frequency, predictors, and outcomes of EDT and ENT detected on gradient-recalled echo imaging (EDT-SVS and ENT-SVS) and INT detected on DWI (INT-DWI) were analyzed. Results: Among 50 thrombectomy-treated acute ischemic stroke patients meeting study criteria, mean age was 70 (±16) years, 44% were women, and presenting National Institutes of Health Stroke Scale score 15 (interquartile range, 8–19). Overall, 21 of 50 (42%) patients showed periprocedural embolic events, including 10 of 50 (20%) with new EDT-SVS, 10 of 50 (20%) with INT-DWI, and 1 of 50 (2%) with both. No patient showed ENT-SVS. On multivariate analysis, model-selected predictors of EDT-SVS were lower initial diastolic blood pressure (odds ratio, 1.09 [95% CI, 1.02–1.16]), alteplase pretreatment (odds ratio, 5.54 [95% CI, 0.94–32.49]), and atrial fibrillation (odds ratio, 7.38 [95% CI, 1.02–53.32]). Classification tree analysis identified pretreatment target occlusion SVS as an additional predictor. On univariate analysis, INT-DWI was less common with internal carotid artery (5%), intermediate with middle cerebral artery (25%), and highest with vertebrobasilar (57%) target occlusions ( P =0.02). EDT-SVS was not associated with imaging/functional outcomes, but INT-DWI was associated with reduced radiological hemorrhagic transformation (0% versus 54%; P <0.01). Conclusions: Among acute ischemic stroke patients treated with thrombectomy, imaging evidence of distal emboli, including EDT-SVS beyond the target occlusion and INT-DWI in novel territories, occur in about 2 in every 5 cases. Predictors of EDT-SVS are pretreatment intravenous fibrinolysis, potentially disrupting thrombus structural integrity; atrial fibrillation, possibly reflecting larger target thrombus burden; lower diastolic blood pressure, suggestive of impaired embolic washout; and pretreatment target occlusion SVS sign, indicating erythrocyte-rich, friable target thrombus.
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Yiin, Gabriel S. C., Dominic P. J. Howard, Nicola L. M. Paul, et al. "Age-Specific Incidence, Outcome, Cost, and Projected Future Burden of Atrial Fibrillation–Related Embolic Vascular Events." Circulation 130, no. 15 (2014): 1236–44. http://dx.doi.org/10.1161/circulationaha.114.010942.
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Bowcock, Emma, Idunn Morris, and Stuart Lane. "Disseminating clot burden post- craniotomy: The difficult balancing act of clot versus haemorrhage post-neurosurgery." Journal of Neuroanaesthesiology and Critical Care 03, no. 03 (2016): 252–58. http://dx.doi.org/10.4103/2348-0548.190078.
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AbstractVenous thromboembolism (VTE) is the most common complication following craniotomy for neoplastic disease. Its occurrence is associated with a significant morbidity and mortality, and balancing the risks for the subsequent development of VTE versus intracranial haemorrhage (ICH) can lead to difficult management decisions for treating clinicians. We present a case of VTE following craniotomy for meningioma complicated by ICH in the presence of a disseminating clot burden that included pulmonary, intra-cardiac and paradoxical arterial embolic sequelae. Management strategies incorporated pharmacological, radiological and surgical methods. We discuss the evidence for VTE prevention and treatment, as well as the role of inferior vena cava filters and thrombectomy. We finally highlight the use of desmopressin as a potential risk factor for VTE, and encourage the need for an individualised approach to peri-operative risk stratification in the neurosurgical intensive care population.
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Ho, Jacky Y. K., Joyce W. Y. Chan, Simon C. Y. Chow, et al. "Application of Cerebral Protection System in Open Mitral Replacement with Extensive Calcified Left Atrial Thrombus." Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery 15, no. 1 (2019): 85–87. http://dx.doi.org/10.1177/1556984519892242.
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Neurological complications remain a major burden in cardiac surgery, despite various intraoperative measures attempting to reduce its occurrence. Advancement of percutaneous approach in valve replacement has brought focus to the use of cerebral protection system (CPS). We reported a novel application of percutaneous CPS in open heart surgery for a patient with an extensive calcified left atrial thrombus to reduce risk of embolic stroke. Although, there is no evidence to advocate routine use of CPS in all open cardiac surgical patients, we believe it is a technically feasible and probably safe approach for neurological protection in high-risk patients.
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Grifoni, Elisa, Davide Giglio, Giulia Guazzini, et al. "Age-related burden and characteristics of embolic stroke of undetermined source in the real world clinical practice." Journal of Thrombosis and Thrombolysis 49, no. 1 (2019): 75–85. http://dx.doi.org/10.1007/s11239-019-01951-5.
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Jagielak, Dariusz, Radoslaw Targonski, and Dariusz Ciecwierz. "First-in-Human Use of the Next-generation ProtEmbo Cerebral Embolic Protection System During Transcatheter Aortic Valve-in-valve Implantation." Interventional Cardiology Review 16, Supplement 1 (2021): 1–4. http://dx.doi.org/10.15420/icr.2021.s1.
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Cerebral embolic protection (CEP) devices aim to reduce the risk of periprocedural cerebrovascular events during transcatheter aortic valve implantation (TAVI). Here, the authors describe the first-in-human experience with the ProtEmbo Cerebral Protection System (Protembis), a next-generation CEP device, during TAVI. This case is part of a larger European trial evaluating the safety and performance of this device. After deployment of the ProtEmbo in the aortic arch, a first transcatheter heart valve was implanted. Despite postdilatation, moderate to severe aortic regurgitation persisted. The operating team decided to perform a valve-in-valve procedure using a second transcatheter heart valve. The ProtEmbo demonstrated good coverage of all three head vessels and no interaction with TAVI catheters in the aortic arch throughout the entire procedure. No adverse events were observed during hospitalisation or follow-up, and there was a significant reduction in aortic regurgitation at follow-up echocardiography. Despite a challenging overall procedure with presumably high embolic burden, diffusion-weighted MRI at follow-up showed a low number (n=3) and volume (156 mm3) of new hyperintense lesions. The first-in-human use of the ProtEmbo was safe and feasible, despite a challenging TAVI valve-in-valve procedure.
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Schäfer, Ulrich. "Safety and Efficacy of Protected Cardiac Intervention: Clinical Evidence for Sentinel Cerebral Embolic Protection." Interventional Cardiology Review 12, no. 02 (2017): 128. http://dx.doi.org/10.15420/icr.2017:19:2.
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Stroke is a well-documented potential risk of structural cardiac interventions. As a result of the far-reaching burden of stroke on patients, caregivers and the healthcare system, new medical interventions and therapies are being developed to help mitigate this risk. One such intervention is the recently FDA-cleared Sentinel™ Cerebral Protection System (Sentinel; Claret Medical, Santa Rosa, CA, USA) designed to capture and remove debris dislodged during transcatheter aortic valve replacement procedures. In the SENTINEL IDE Study, and in a more recent all-comers trial, Sentinel significantly reduced periprocedural strokes by 63 and 70 % respectively. In this paper, we review the growing body of evidence supporting the use of Sentinel in transcatheter aortic valve replacement and other endovascular procedures.
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Lu, Min, and Erik Nathan Hansen. "Hydrogen Peroxide Wound Irrigation in Orthopaedic Surgery." Journal of Bone and Joint Infection 2, no. 1 (2017): 3–9. http://dx.doi.org/10.7150/jbji.16690.
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Abstract. As the burden of deep hardware infections continues to rise in orthopaedics, there is increasing interest in strategies for more effective debridement of colonized tissues and biofilm. Hydrogen peroxide has been used medically for almost a century, but its applications in orthopaedic surgery have yet to be fully determined. The basic science and clinical research on the antiseptic efficacy of hydrogen peroxide have demonstrated its efficacy against bacteria, and it has demonstrated potential synergy with other irrigation solutions such as chlorhexidine and povidone-iodine. While hydrogen peroxide is effective in infection reduction, there are concerns with wound healing, cytotoxicity, and embolic phenomena, and we recommend against hydrogen peroxide usage in the treatment of partial knee replacements, hemiarthroplasties, or native joints. Additionally, due to the potential for oxygen gas formation, hydrogen peroxide should not be used in cases of dural compromise, when pressurizing medullary canals, or when irrigating smaller closed spaces to avoid the possibility of air embolism. Finally, we present our protocol for irrigation and debridement and exchange of modular components in total joint arthroplasty, incorporating hydrogen peroxide in combination with povidone-iodine and chlorhexidine.
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Duynstee, Friso, Ruud W. M. Keunen, Agnes van Sonderen, et al. "Impact of the Haga Braincare Strategy on the burden of haemodynamic and embolic strokes related to cardiac surgery." Interactive CardioVascular and Thoracic Surgery 25, no. 5 (2017): 765–71. http://dx.doi.org/10.1093/icvts/ivx171.
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Marinescu, Marilena, James Bouley, Juyu Chueh, Marc Fisher, and Nils Henninger. "Clot Injection Technique Affects Thrombolytic Efficacy in a Rat Embolic Stroke Model: Implications for Translaboratory Collaborations." Journal of Cerebral Blood Flow & Metabolism 34, no. 4 (2014): 677–82. http://dx.doi.org/10.1038/jcbfm.2014.1.
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Current recommendations encourage the use of embolic stroke (ES) models and replication of results across laboratories in preclinical research. Since such endeavors employ different surgeons, we sought to ascertain the impact of injection technique on outcome and response to thrombolysis in an ES model. Embolic stroke was induced in Male Wistar Kyoto rats ( n=166) by a fast or a slow clot injection (CI) technique. Saline or recombinant tissue plasminogen activator (rtPA) was given at 1 hour after stroke. Flow rate curves were assessed in 24 animals. Cerebral perfusion was assessed using laser Doppler flowmetry. Edema corrected infarct volume, hemispheric swelling, hemorrhagic transformation, and neurologic outcome were assessed at 24 hours after stroke. Clot burden was estimated in a subset of animals ( n=40). Slow CI resulted in significantly smaller infarct volumes ( P=0.024) and better neurologic outcomes ( P=0.01) compared with fast CI at 24 hours. Unexpectedly, rtPA treatment attenuated infarct size in fast ( P<0.001) but not in slow CI experiments ( P=0.382), possibly related to reperfusion injury as indicated by greater hemorrhagic transformation ( P<0.001) and hemispheric swelling ( P<0.05). Outcome and response to thrombolysis after ES are operator dependent, which needs to be considered when comparing results obtained from different laboratories.
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Broussalis, Erasmia, Christoph Griessenauer, Sebastian Mutzenbach, et al. "Reduction of cerebral DWI lesion burden after carotid artery stenting using the CASPER stent system." Journal of NeuroInterventional Surgery 11, no. 1 (2018): 62–67. http://dx.doi.org/10.1136/neurintsurg-2018-013869.
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IntroductionDespite various measures to protect against distal embolization during carotid artery stenting (CAS), periprocedural ischemic lesions are still encountered.ObjectiveTo evaluate the periprocedural cerebral diffusion weighted imaging (DWI) lesion burden after CASPER stent placement.MethodsPatients who underwent CAS using the CASPER stent system were reviewed. Degrees of carotid stenosis and plaque configuration were determined. All patients were pretreated with dual antiplatelet agents and cerebral pre- and postprocedural MRI was obtained. All CAS procedures were performed by a single operator.ResultsA total of 110 patients with severe carotid artery stenosis (median degree of stenosis 80%, median length of stenosis 10 mm) were treated with CAS. Hypoechogenic or heterogeneous, mostly hypoechogenic, plaques were documented in 48.6% (52/107) of patients. Carotid ulceration was present in 15.9% (17/107). Postprocedurally, 7.3% (8/110) of patients were found to have ischemic DWI lesions. They were asymptomatic in all patients. Follow-up at 90 days was available in 88.2% (97/110) of patients with excellent functional outcome (modified Rankin Scale score 0–1) in 95.9% (93/97).ConclusionCarotid artery stenting using the new CASPER stent in combination with a distal embolic protection device is safe and results in a lower rate of periprocedural DWI lesion burden compared with reported results for historic controls.
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Tandon, Karman, David Tirschwell, W. T. Longstreth, Bryn Smith, and Nazem Akoum. "Embolic stroke of undetermined source correlates to atrial fibrosis without atrial fibrillation." Neurology 93, no. 4 (2019): e381-e387. http://dx.doi.org/10.1212/wnl.0000000000007827.
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ObjectiveTo examine the hypothesis that atrial fibrosis and associated atrial cardiopathy may be in the causal pathway of cardioembolic stroke independently of atrial fibrillation (AF) by comparing atrial fibrosis burden between patients with embolic stroke of undetermined source (ESUS), patients with AF, and healthy controls.MethodsWe used late-gadolinium-enhancement MRI to compare atrial fibrosis in 10 patients with ESUS against 10 controls (no stroke, no AF) and 10 patients with AF. Fibrosis was compared between groups, controlling for stroke risk factors.ResultsMean age was 51 ± 15 years, and 43% of participants were female. Patients with ESUS had more atrial fibrosis than controls (16.8 ± 5.7% vs 10.6 ± 5.7%, p = 0.019) and similar fibrosis compared to patients with AF (17.8 ± 4.8%, p = 0.65). Odds ratios of ESUS per quartile of fibrosis were 3.22 (95% CI [CI] 1.11–9.32, p = 0.031, unadjusted) and 3.17 (95% CI 1.05–9.52, p = 0.041, CHA2DVASc score adjusted). Patients with >12% fibrosis had a higher percentage of ESUS (77.8% vs 27.3%, p = 0.02), and patients with >20% fibrosis had the highest proportion of ESUS (4 of 5).ConclusionsPatients with ESUS exhibit similar atrial fibrosis compared to patients with AF and more fibrosis than healthy controls. Fibrosis is associated with ESUS after controlling for stroke risk factors, supporting the hypothesis that fibrosis is in the causal pathway of cardioembolic stroke independently of AF. Prospective studies are needed to assess the role of anticoagulation in primary and secondary stroke prevention in patients with high atrial fibrosis.
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Kovacs, Flora, and Sumaira Macdonald. "Strategies and Outcomes for Proximal and Distal Embolic Protection Devices – A Review." Interventional Cardiology Review 7, no. 2 (2012): 115. http://dx.doi.org/10.15420/icr.2012.7.2.115.
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Both carotid endarterectomy (CEA) and carotid artery stenting (CAS) are associated with small, but clinically important and discrepant, rates of procedural complications, including cerebral and myocardial ischaemic events, cranial nerve injury and access site haematoma. Embolic protection devices (EPDs) may lower the rate of ipsilateral ischaemic events during CAS and are considered by the majority of interventionists to be mandatory during CAS, although there are no available data from randomised trials based on clinical outcomes to support this practice (perhaps because many thousands of patients would be required to adequately power a trial based on stroke and death endpoints). A recent systematic review of non-randomised data supports the use of EPDs. Worldwide experience demonstrates that all available protection strategies will capture macroemboli generated during endovascular manipulation of carotid bifurcation plaque, thus clearly implying an added level of protection for the brain when these systems are employed, but different philosophies of protection manage the microembolic burden of CAS (i.e. those particles less than 1 mm in diameter) in very different ways. These differences may be assessed by the evaluation of microembolic signals (MES) on transcranial Doppler (TCD) and of new hyperintensities (‘new white lesions’) on diffusion-weighted magnetic resonance imaging (DWMRI) of the brain. Differences between proximal and distal systems may assume clinical relevance, but further work is required before definitive conclusions can be drawn. This article focuses on the clinical and subclinical differences between protection strategies and provides a pragmatic treatment paradigm to support clinical decision-making.
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Kim, Jang Young, Junghan Yoon, Seung Hwan Lee, et al. "Efficacy of Embolic Protection using PercuSurge GuardWire System During Primary Percutaneous Coronary Intervention with the Lesions Suggesting Large Thrombus Burden." Korean Circulation Journal 33, no. 12 (2003): 1103. http://dx.doi.org/10.4070/kcj.2003.33.12.1103.
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Nicolau, André M., Ramon Corbalan, Jose C. Nicolau, et al. "Efficacy and safety of edoxaban compared with warfarin according to the burden of diseases in patients with atrial fibrillation: insights from the ENGAGE AF-TIMI 48 trial." European Heart Journal - Cardiovascular Pharmacotherapy 6, no. 3 (2019): 167–75. http://dx.doi.org/10.1093/ehjcvp/pvz061.
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Abstract Aims Non-vitamin K antagonist oral anticoagulants represent a new option for prevention of embolic events in patients with atrial fibrillation (AF). However, little is known about the impact of non-cardiac comorbidities on the efficacy and safety profile of these drugs. Methods and results In a post hoc analysis of the ENGAGE AF-TIMI 48 trial, we analysed 21 105 patients with AF followed for an average of 2.8 years and randomized to either a higher-dose edoxaban regimen (HDER), a lower-dose edoxaban regimen, or warfarin. We used the updated Charlson Comorbidity Index (CCI) to stratify the patients according to the burden of concomitant disease (CCI = 0, 1, 2, 3, and ≥4). The treatment groups were then compared for safety, efficacy, and net clinical outcomes across CCI categories. There were 32.0%, 7.3%, 42.1%, 12.7%, and 6.0% of patients with CCI scores of 0, 1, 2, 3, and ≥4, respectively. A CCI score ≥4 was associated with significantly higher rates of thromboembolic events, bleeding, and death compared to CCI = 0 (P &lt; 0.05 for each). The annualized rates of the primary net clinical outcome (stroke/systemic embolism, major bleeding, or death) for CCI = 0, 1, 2, 3, or ≥4 were 5.9%, 8.7%, 6.6%, 10.3%, and 13.6% (Ptrend &lt; 0.001). There were no significant interactions between treatment with HDER vs. warfarin and efficacy, safety, and net outcomes across the CCI groups (P-interaction &gt; 0.10 for each). Conclusion Although increasing CCI scores are associated with worse outcomes, the efficacy, safety, and net clinical outcomes of edoxaban vs. warfarin were independent of the degree of comorbidity present.
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Saadat, Payam, Alijan Ahmadi Ahangar, Mansor Babaei, et al. "Relationship of Serum Uric Acid Level with Demographic Features, Risk Factors, Severity, Prognosis, Serum Levels of Vitamin D, Calcium, and Magnesium in Stroke." Stroke Research and Treatment 2018 (July 2, 2018): 1–8. http://dx.doi.org/10.1155/2018/6580178.
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Introduction. Stroke is one of the most common neurological disorders with high mortality rates. A large financial burden is imposed on the families and health systems of countries in addition to the problems related to the disabilities caused by the disease for the patients. Extensive research is being conducted on the disease, including studies seeking possible relationships between some biomarkers such as uric acid and stroke. Methods. This descriptive-analytic cross-sectional study was conducted on 170 stroke patients at Babol Ayatollah Rohani Hospital during 2015-2016. Serum uric acid (SUA) levels were measured and recorded at admission time. Patients’ demographic data as well as the stroke type and some of their risk factors were entered in a checklist. The data were analyzed by SPSS.v.23 using chi-square and logistic regression tests. P<0.05 was considered as significant in all analyses. Results. Of the total 170 included patients, 57% had normal, 25% had low, and the remaining patients (18%) had high SUA levels. There was no significant difference in SUA levels in different types of stroke in both genders. Diabetic ischemic embolic patients had higher levels of SUA than diabetic ischemic thrombotic cases. Patients with low magnesium levels had higher rate of low levels of SUA in ischemic stroke. Conclusion. Serum uric acid levels are not associated with stroke types and gender. Diabetic embolic ischemic stroke cases had high SUA levels than thrombotic types and in ischemic stroke patients with low serum levels of magnesium, SUA levels were also lower.
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Hanna, Lydia, and Richard Gibbs. "Brain Protection in the Endo-Management of Proximal Aortic Aneurysms." Hearts 1, no. 2 (2020): 25–37. http://dx.doi.org/10.3390/hearts1020005.
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Neurological brain injury (NBI) remains the most feared complication following thoracic endovascular aortic repair (TEVAR), and can manifest as clinically overt stroke and/or more covert injury, detected only on explicit neuropsychological testing. Microembolic signals (MES) detected on transcranial Doppler (TCD) monitoring of the cerebral arteries during TEVAR and the high prevalence and incidence of new ischaemic infarcts on diffusion-weighted magnetic resonance imaging (DW-MRI) suggests procedure-related solid and gaseous cerebral microembolisation to be an important cause of NBI. Any intervention that can reduce the embolic burden during TEVAR may, therefore, help mitigate the risk of stroke and the covert impact of ischaemic infarcts to the function of the brain. This perspective article provides an understanding of the mechanism of stroke and reviews the available evidence regarding potential neuroprotective strategies that target high-risk procedural steps of TEVAR to reduce periprocedural cerebral embolisation.
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Green, Clara, Adnan Nadir, Will Lester, and Davinder Dosanjh. "Coronary artery thrombus resulting in ST-elevation myocardial infarction in a patient with COVID-19." BMJ Case Reports 14, no. 8 (2021): e243811. http://dx.doi.org/10.1136/bcr-2021-243811.
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COVID-19 is a prothrombotic condition that is also associated with raised troponin levels and myocardial damage. We present a case of a 54-year-old man who was admitted with respiratory failure due to COVID-19 and developed a ST-elevation myocardial infarction (STEMI) during his admission. His coronary angiogram did not show any significant coronary artery disease other than a heavily thrombosed right coronary artery. In view of heavy thrombus burden, the right coronary artery was treated with thrombus retrieval using a distal embolic protection device in addition to manual thrombectomy and direct (intracoronary) thrombolysis without the need for implantation of a coronary stent. After successful revascularisation, triple antithrombotic therapy was instituted with an oral anticoagulant in addition to dual antiplatelets. This case illustrates the association of COVID-19 with coronary artery thrombosis, which may require disparate management of a STEMI than that resulting from atherosclerotic coronary artery disease.
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Scarpone, Marialuisa, Edina Cenko, and Olivia Manfrini. "Coronary No-Reflow Phenomenon in Clinical Practice." Current Pharmaceutical Design 24, no. 25 (2018): 2927–33. http://dx.doi.org/10.2174/1381612824666180702112536.
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Timely delivered coronary revascularization with no residual anatomical stenosis does not always lead to prompt restoration of anterograde coronary flow and complete myocardial reperfusion. This condition is known as coronary no-reflow and is associated with major clinical adverse events and poor prognosis. The pathophysiology of no-reflow phenomenon is still poorly understood. Proposed mechanisms include distal microembolization of thrombus and plaque debris, ischemic injury, endothelial dysfunction and individual susceptibility to microvascular dysfunction/obstruction. Older age, diabetes, hypercholesterolemia, prolonged ischemic time, hemodynamic instability, high thrombus burden, complex angiographic lesions and multivessel disease are frequently reported to be associated with the no-reflow phenomenon. There is no general consensus on the correct prevention and management of no-reflow. Non-pharmacological measures such as distal embolic protection devices and manual thrombus aspiration did not result in improved flow or reduction of infarct size. Current preventive measures include reduction of time from symptoms onset to reperfusion therapy, and intracoronary administration of vasodilators such as adenosine, verapamil or nitroprusside.
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Aroney, Nicholas, Tiffany Patterson, Christopher Allen, Simon Redwood, and Bernard Prendergast. "Neurocognitive Status after Aortic Valve Replacement: Differences between TAVI and Surgery." Journal of Clinical Medicine 10, no. 8 (2021): 1789. http://dx.doi.org/10.3390/jcm10081789.
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Over the past decade, indications for transcatheter aortic valve implantation (TAVI) have progressed rapidly—procedural numbers now exceed those of surgical aortic valve replacement (SAVR) in many countries, and TAVI is now a realistic and attractive alternative to SAVR in low-risk patients. Neurocognitive outcomes after TAVI and SAVR remain an issue and sit firmly under the spotlight as TAVI moves into low-risk cohorts. Cognitive decline and stroke carry a significant burden and predict future functional decline, reduced mobility, poor quality of life and increased mortality. Early TAVI trials used varying neurocognitive definitions, and outcomes differed significantly as a result. Recent international consensus statements defining endpoints following TAVI and SAVR have standardised neurological outcomes and facilitate interpretation and comparison between trials. The latest TAVI and SAVR trials have demonstrated more consistent and favourable neurocognitive outcomes for TAVI patients, and cerebral embolic protection devices offer the prospect of further refinement and improvement.
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Schaefer, Jan H., Christoph Stephan, Christian Foerch, and Waltraud Pfeilschifter. "Ischemic stroke in human immunodeficiency virus-positive patients: An increasingly age-related comorbidity?" European Stroke Journal 5, no. 3 (2020): 252–61. http://dx.doi.org/10.1177/2396987320927672.
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Introduction The global incidence of ischemic stroke among patients with human immunodeficiency virus is increasing. The aim of this controlled case analysis was to study patient characteristics, stroke etiologies, and risk factors in human immunodeficiency virus-positive patients in a medical system with easy access to antiretroviral therapies. Patients and methods We conducted a retrospective, observational study of human immunodeficiency virus-positive patients treated in our stroke unit and outpatient clinic in Germany between 2012 and 2018. A control group of all patients treated for acute ischemic stroke in 2018 was used to elicit possible differences in stroke localization, etiology, and distribution of risk factors. Results Out of 3615 patients with an acute ischemic stroke, 24 (0.7%) were newly or previously diagnosed as human immunodeficiency virus-positive. Strokes in this cohort were caused by large-vessel disease (37.5%), small-vessel disease (20.8%), cryptogenic-embolism (20.8%), vasculitis (16.7%), and cardio-embolism (4.2%). Large-vessel disease-related strokes were more often located in the posterior circulation (77.8%). Compared to the control group, cardio-embolic strokes were less and vasculitis and large-vessel disease more frequent. Human immunodeficiency virus-positive patients were younger at stroke onset (53.7 ± 12.8 vs. 70.2 ± 14.6 years, p = 0.05). Discussion Although the prevalence of human immunodeficiency virus-infection among patients treated for acute ischemic strokes appears low, this collective merits special attention due to a high burden of potentially modifiable risk factors and vasculitis. Conclusion Compared to previous studies, age at stroke onset was one of the highest, supporting the hypothesis that as antiretroviral therapy increases the life expectancy of people living with HIV/AIDS, they will be increasingly affected by cardiovascular disease. Human immunodeficiency virus-related cerebral vasculitis was associated with high mortality (75%).
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Siwaprapakorn, Warawut, Manat Panamonta, Arnkisa Chaikitpinyo, et al. "Original article. Childhood infective endocarditis in Khon Kaen University Hospital from 1992 to 2011." Asian Biomedicine 8, no. 6 (2014): 717–26. http://dx.doi.org/10.5372/1905-7415.0806.349.
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AbstractBackground: Infective endocarditis (IE) is an important cause of child morbidity and mortality, but the current burden of the disease in Thai children is unknown.Objectives: To determine the current burden of IE in Thai children.Patients and Methods: The records of all children aged <15 years admitted to Khon Kaen University Hospital from 1992 to 2011 were reviewed.Results: Of 69,822 admissions, 56 patients fulfilled the modified Duke criteria for definite IE giving a rate of 0.8 cases per 1,000 admissions. Age at diagnosis was 7.9 ± 3.8 years (range, 8 days to 14.8 years). There was congenital heart disease in 38 (68%) patients, rheumatic heart disease (RHD) in 10 (18%), and no previous heart disease in 8 (14%). RHD was a less frequent underlying disease during the latter half (2002-2011) of the period studied (1/34 vs. 9/22, P < 0.001). Blood cultures were positive for pathogens in 34 (61%) patients with 11 cases of Streptococcus viridians and 8 cases of Staphylococcus aureus infections. Vegetations on echocardiography were present in 46 (82%) patients. For 8 embolic events, patients with large vegetations had a higher rate (4/6) than patients with small and no vegetations (4/50) (P < 0.003). In-hospital mortality was 11%. Eight patients with S. aureus infection had a higher mortality (5/8) than 26 patients (1/26) infected with other pathogens (P < 0.001).Conclusion: The changing epidemiology of pediatric IE was toward fewer children with RHD. Mortality among children with IE was higher in those with S. aureus infection.
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Arora, Mukta, Yanjun Chen, Lindsey Hageman, et al. "Burden of Morbidity Borne By Survivors of Multiple Myeloma (MM) Treated with Autologous Blood or Marrow Transplant (BMT) — Results of the BMT Survivor Study (BMTSS)." Blood 132, Supplement 1 (2018): 2127. http://dx.doi.org/10.1182/blood-2018-99-112702.
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Abstract Background: Autologous BMT (either as a planned procedure after completion of initial treatment or as salvage therapy for relapse) is considered standard of care for patients with MM. Therapeutic advances have resulted in significant improvement in survival, necessitating an understanding of the burden of morbidity borne by MM survivors - an understudied topic. We addressed this gap by conducting a comprehensive evaluation of chronic health conditions (CHCs) in MM patients treated with autologous BMT using BMTSS. Methods: Patients were eligible if they had undergone autologous BMT for MM between 1974 and 2014 at one of 3 BMT centers, had survived for ≥2y after BMT, and were ≥18y of age at participation. Of the 1,116 subjects approached, 630 (56.5%) participated. A nearest-age sibling was invited to participate in the study, and served as an unaffected comparison group (n=289). Survivors and siblings completed a 231-item BMTSS survey that included questions regarding CHCs, including age at onset of each CHC. Each CHC was scored (CTCAE v 4.03) to determine severity. Using multivariable logistic regression, we determined the risk of any severe (grade 3) or life-threatening (grade 4) CHC in survivors compared with siblings, adjusting for age at study, sex, race/ethnicity, education, annual household income and insurance status. Information on initial pre-BMT treatment exposures, conditioning regimens and post-BMT maintenance treatment was abstracted from medical records. Cumulative incidence of CHCs overall, and by specific types were calculated for BMT survivors, treating death as a competing risk. Cox regression was used to determine clinical, demographic and therapeutic predictors of CHCs in BMT survivors. Results: Mean age at BMT was 57.6±8.5y and at survey was 64.2±7.9y. Mean interval between BMT and study participation was 6.6±3.7y; 58% were males, and 62% were non-Hispanic white. Conditioning was melphalan based in 98%, TBI was used in only 5.5%. Mean age at survey for the siblings was 64±8.08y; 58% were male and 84% were non-Hispanic whites. BMT survivors vs. siblings: Overall, 43.3% of the survivors reported a grade 3-4 CHC, placing them at a 1.4-fold higher odds when compared with siblings (95%CI, 1.0-1.9, p=0.03). The odds of developing the following CHCs were significantly higher in BMT survivors when compared with siblings (Fig 1): cataracts (odds ratio [OR]=2.3; 95%CI, 1.4-3.7, p=0.0006), venous thrombo-embolism (VTE: OR=2.4, 95%CI, 1.2-4.6 p=0.01), and subsequent neoplasms (SNs: OR=4.4, 95% CI, 1.8-10.6, p=0.0009). BMT survivors only: 10y cumulative incidence of any grade 3-4 CHC in BMT survivors was 57.6% ± 3.2% (Fig 2). Cataracts: 10y cumulative incidence of cataracts was 24.8% ± 2.7%. Older age at BMT (≥60y: relative risk [RR]=3.3; 95%CI, 2.2-5.1, p <0.0001); TBI-based conditioning (RR=2.3; 95%CI, 1.1-4.8, p=0.02); and female sex (RR=1.6; 95%CI, 1.1-2.4, p=0.01) were associated with increased risk of cataracts. VTE: 10y cumulative incidence of thrombo-embolic events was 10.5% ± 1.6%. Older age at BMT (≥60y: RR=2.2; 95%CI, 1.2-3.9, p=0.007); non-Hispanic white race/ethnicity (RR=4.8; 95%CI, 2.0-11.2, p=0.0003); and pre-BMT exposure to doxorubicin (RR=2.1; 95%CI, 1.04-4.04, p=0.04) were associated with increased risk for VTE. SNs:10y cumulative incidence of SN was 14.0% ± 2.5%. Older age at BMT (≥60y: RR=2.2; 95%CI, 1.2-4.2, p=0.01), pre-BMT exposure to cyclophosphamide (RR=2.9, 95%CI,1.3-6.5, p=0.01) and IMiDs (thalidomide or lenalidomide: RR=3.8, 95%CI, 1.6-9.2, p=0.003); and non-Hispanic white race/ethnicity (RR=2.3; 95%CI, 1.1-4.8, p=0.03) were associated with increased risk for SNs. Conclusion: The 10y cumulative incidence of a severe/life-threatening chronic health condition approaches 60% in multiple myeloma patients treated with autologous BMT. Cataracts, thrombo-embolic events and subsequent neoplasms constitute the largest burden of morbidity. This study identifies demographic factors and treatment exposures associated with increased risk of chronic health conditions, and provides evidence for close monitoring of these survivors to anticipate and manage morbidity. Disclosures Weisdorf: Seattle Genetics: Consultancy; Pharmacyclics: Consultancy; FATE: Consultancy; SL Behring: Consultancy; Equillium: Consultancy. Forman:Mustang Therapeutics: Other: Licensing Agreement, Patents & Royalties, Research Funding.
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Angeles, Arkhjamil, Wayne Hung, and Winson Y. Cheung. "Real world eligibility of treatment-refractory stage IV colorectal cancer patients for palliative intent regorafenib monotherapy." Journal of Clinical Oncology 35, no. 15_suppl (2017): e15007-e15007. http://dx.doi.org/10.1200/jco.2017.35.15_suppl.e15007.
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e15007 Background: The CORRECT trial demonstrated overall survival benefits of regorafenib monotherapy in patients with metastatic colorectal cancer (CRC) who were refractory to prior chemotherapy and biological therapy. However, stringent criteria used to determine treatment eligibility in the trial setting may limit its external validity in the real world. We aimed to examine treatment attrition rates and eligibility of regorafenib in routine clinical practice. Methods: All patients diagnosed with metastatic CRC between 2009 and 2014 who received 2 or more lines of systemic therapy at the British Columbia Cancer Agency were identified. During the study timeframe, cetuximab (cmab) and panitumumab (pmab) were only used in the chemo-refractory setting. Data on clinical factors, pathological variables and outcomes were ascertained and analyzed. Eligibility was defined based on criteria outlined in the CORRECT trial. Results: A total of 391 patients were included among whom only 39% were considered eligible for regorafenib. Median age was 61 (range 22-84) years. 247 (63%) were men, 305 (78%) were Caucasian, and 237 (60%) had a colonic primary. The disease burden at diagnosis was high: 267 (81%) had lymph node involvement, and 225 (59%) had distant metastases. In patients previously treated with cmab, main reasons for regorafenib ineligiblity were Eastern Cooperative Oncology Group performance status (ECOG PS) > 1 (26.9%), aspartate aminotransferase (AST) > 2 x upper limit of normal (ULN) (6.5%), and arterio-venous thrombotic or embolic events in the preceding 6 months (6.5%). In the group treated with pmab previously, main reasons for ineligibility were ECOG PS > 1 (46.6%), total bilirubin > 1.5 x ULN (14.1%), and thrombotic or embolic events in the past 6 months (5.7%). Additional analyses showed that regorafenib-eligible patients had increased median overall survival compared to ineligible patients (44.0 vs 37.1 months, P= 0.028). Conclusions: The strict trial eligibility criteria disqualified the majority of real world patients with metastatic CRC for regorfenib. As ineligibility predicts poorer outcomes, trials aimed at serving protocol-ineligible patients are warranted.
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Lee, Ji Hyun, In Tae Moon, Youngjin Cho, et al. "Left Atrial Diameter and Atrial Ectopic Burden in Patients with Embolic Stroke of Undetermined Source: Risk Stratification of Atrial Fibrillation with Insertable Cardiac Monitor Analysis." Journal of Clinical Neurology 17, no. 2 (2021): 213. http://dx.doi.org/10.3988/jcn.2021.17.2.213.
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Carling, Ulrik, Bård Røsok, Pål-Dag Line, and Eric J. Dorenberg. "ALBI and P-ALBI grade in Child-Pugh A patients treated with drug eluting embolic chemoembolization for hepatocellular carcinoma." Acta Radiologica 60, no. 6 (2018): 702–9. http://dx.doi.org/10.1177/0284185118799519.
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Background Treatment outcome for hepatocellular carcinoma (HCC) is related to tumor burden and liver function. Grading systems assessing liver function need validation in different clinical settings. Purpose To evaluate drug-eluting embolic transarterial chemoembolization (DEE-TACE) in Child–Pugh A HCC with respect to albumin-bilirubin (ALBI) and platelet-albumin-bilirubin (P-ALBI) grade. Material and Methods Forty-nine patients with Child–Pugh class A, diagnosed with HCC and allocated to DEE-TACE treatment, were retrospectively analyzed regarding tumor and treatment characteristics, radiological response (mRECIST) one month post treatment, overall survival (OS), and adverse events (AEs; CTCAE, grades ≥3) with respect to ALBI and P-ALBI grade. Results There were 21 ALBI 1 patients, 29 P-ALBI 1 patients, and 19 patients were both ALBI and P-ALBI 1. Objective response rate was 74% with no statistically significant difference for ALBI (1 vs. 2; P = 0.08), or P-ALBI (1 vs. 2; P = 0.49). OS was 14.8 months (range = 1.7–62.0; ALBI 1 vs. 2: P = 0.08; P-ALBI 1 vs. 2: P = 0.003). OS in responders with ALBI 1 and 2 was 28.9 vs.10.2 months ( P = 0.02), and P-ALBI 1 and 2 was 26.7 vs. 8.6 months ( P < 0.001). In multivariate analyses, both ALBI 2 (HR = 2.4, P = 0.02) and P-ALBI 2 (HR = 3.3, P < 0.01) were negative prognostic factors for survival. There were 15 AEs in 13 patients, with hepatic failure only occurring in ALBI 2 and P-ALBI 2 patients. Conclusion P-ALBI grade 1 and 2 differentiated survival in Child–Pugh A patients treated with DEE-TACE. Both grading systems can differentiate survival in patients responding to treatment.
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Sansevere, Arnold J., Melissa L. DiBacco, Alireza Akhondi-Asl, et al. "EEG features of brain injury during extracorporeal membrane oxygenation in children." Neurology 95, no. 10 (2020): e1372-e1380. http://dx.doi.org/10.1212/wnl.0000000000010188.
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ObjectiveTo examine EEG features of major pathophysiology in children undergoing extracorporeal membrane oxygenation (ECMO).MethodsThis was a single-center, retrospective study of 201 pediatric patients on ECMO, using the first 24 hours of continuous EEG (cEEG) monitoring, collating background activity and electrographic seizures (ES) with imaging, ECMO type, and outcome.ResultsSeverely abnormal cEEG background occurred in 12% (25/201), and was associated with death (sensitivity 0.23, specificity 0.97). ES occurred in 16% (33/201) within 3.2 (0.6–20.3) hours (median [interquartile range]) of cEEG commencement, and higher ES burden was associated with death. ES was always associated with ipsilateral injury (p = 0.006), but occurred in only one-third of cases with abnormal imaging. In 28 patients with isolated hemisphere lesion, type of arterial ECMO cannulation was associated with side of injury: right carotid cannulation was associated with right hemisphere lesions, and ascending aorta cannulation with left hemisphere lesions (odds ratio, 0.29 [95% confidence interval, 0.08–0.98], p = 0.03).ConclusionsAfter starting ECMO, cEEG background activity has the potential to inform prognosis. Type of arterial (carotid vs aortic) ECMO correlates with side of focal cerebral injury, which in ≈33% is associated with presence of ES. We hypothesize that the differential distribution reflects abnormal flow dynamics or embolic injury.
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Zhang, Yuying, Evan D. Bander, Yurim Lee, Celia Muoser, Chris B. Schaffer, and Nozomi Nishimura. "Microvessel occlusions alter amyloid-beta plaque morphology in a mouse model of Alzheimer’s disease." Journal of Cerebral Blood Flow & Metabolism 40, no. 10 (2019): 2115–31. http://dx.doi.org/10.1177/0271678x19889092.
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Vascular dysfunction is correlated to the incidence and severity of Alzheimer’s disease. In a mouse model of Alzheimer’s disease (APP/PS1) using in vivo, time-lapse, multiphoton microscopy, we found that occlusions of the microvasculature alter amyloid-beta (Aβ) plaques. We used several models of vascular injury that varied in severity. Femtosecond laser-induced occlusions in single capillaries generated a transient increase in small, cell-sized, Aβ deposits visualized with methoxy-X04, a label of fibrillar Aβ. After occlusions of penetrating arterioles, some plaques changed morphology, while others disappeared, and some new plaques appeared within a week after the lesion. Antibody labeling of Aβ revealed a transient increase in non-fibrillar Aβ one day after the occlusion that coincided with the disappearance of methoxy-X04-labeled plaques. Four days after the lesion, anti-Aβ labeling decreased and only remained in patches unlabeled by methoxy-X04 near microglia. Histology in two additional models, sparse embolic occlusions from intracarotid injections of beads and infarction from photothrombosis, demonstrated increased labeling intensity in plaques after injury. These results suggest that microvascular lesions can alter the deposition and clearance of Aβ and confirm that Aβ plaques are dynamic structures, complicating the interpretation of plaque burden as a marker of Alzheimer’s disease progression.
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Peacock, W. Frank, Zubaid Rafique, and Adam J. Singer. "Direct-Acting Oral Anticoagulants: Practical Considerations for Emergency Medicine Physicians." Emergency Medicine International 2016 (2016): 1–13. http://dx.doi.org/10.1155/2016/1781684.
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Nonvalvular atrial fibrillation- (NVAF-) related stroke and venous thromboembolism (VTE) are cardiovascular diseases associated with significant morbidity and economic burden. The historical standard treatment of VTE has been the administration of parenteral heparinoid until oral warfarin therapy attains a therapeutic international normalized ratio. Warfarin has been the most common medication for stroke prevention in NVAF. Warfarin use is complicated by a narrow therapeutic window, unpredictable dose response, numerous food and drug interactions, and requirements for frequent monitoring. To overcome these disadvantages, direct-acting oral anticoagulants (DOACs)—dabigatran, rivaroxaban, apixaban, and edoxaban—have been developed for the prevention of stroke or systemic embolic events (SEE) in patients with NVAF and for the treatment of VTE. Advantages of DOACs include predictable pharmacokinetics, few drug-drug interactions, and low monitoring requirements. In clinical studies, DOACs are noninferior to warfarin for the prevention of NVAF-related stroke and the treatment and prevention of VTE as well as postoperative knee and hip surgery VTE prophylaxis, with decreased bleeding risks. This review addresses the practical considerations for the emergency physician in DOAC use, including dosing recommendations, laboratory monitoring, anticoagulation reversal, and cost-effectiveness. The challenges of DOACs, such as the lack of specific laboratory measurements and antidotes, are also discussed.
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Kuchela, Arun, Gabor Sutsch, William E. Downey, et al. "Embolic volume retrieved during native coronary percutaneous coronary intervention with distal protection is far lower than during saphenous vein graft percutaneous coronary intervention regardless of plaque burden." Journal of the American College of Cardiology 41, no. 6 (2003): 71. http://dx.doi.org/10.1016/s0735-1097(03)80920-8.
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Clancy, U., D. J. Garcia, W. Hewins, et al. "30 Informant-Reported Decline Associates with Silent Acute Stroke Lesions and Worse Small Vessel Disease in Mild Stroke Patients." Age and Ageing 50, Supplement_1 (2021): i7—i11. http://dx.doi.org/10.1093/ageing/afab029.09.
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Abstract Introduction Small vessel disease (SVD) commonly causes stroke and dementia. Early clinical predictors of disease progression are lacking. We aimed to determine whether informant reports of chronic cognitive/functional decline, prerequisites for dementia diagnosis, are associated with (a)baseline SVD burden, measured by Fazekas scores and (b)SVD change, measured by incident subcortical Diffusion-weighted Imaging (DWI) lesions. Method We prospectively recruited patients with mild ischaemic stroke, performed diagnostic MRI, and invited participants to repeat MRI 3- to 6-monthly. Informants completed the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) prior to baseline visit, a 16-item questionnaire which assesses patients’ cognitive and functional decline in the preceding ten years. Scores range from 1–5: a score above 3.3 has high sensitivity/specificity for dementia post-stroke. We conducted linear regression with IQCODE as the dependent variable, adjusting for age, sex, baseline MoCA, disability (modified Rankin Scale). Results We recruited 106 participants (mean age 67 years;range 40–86;33% female). Ninety-three informant questionnaires were returned. IQCODE associated with baseline Fazekas score; Fazekas 6 (β = 0.28, p = 0.04) vs. Fazekas 3 (β = 0.03, p = 0.67), R2 = 0.11, adjusted for age, sex, baseline MoCA, disability. Incident DWI lesions were common (15/106; 14/15 subcortical; no active embolic sources; median 67 days post-stroke). Four were asymptomatic, two reported stroke-like symptoms and nine had neuropsychiatric/non-focal symptoms. IQCODE was higher in those with a new lesion vs. without (β = 0.21, p = 0.02), R2 = 0.09, while age (β = −0.004, p = 0.19), MoCA (β = −0.006, p = 0.56) and disability (β = 0.06, p = 0.2) were not. Conclusions Higher SVD burden and incident, mostly “silent” stroke lesions associate more strongly with informant concerns of cognitive/functional decline than age or objective cognitive tests. These findings are novel in an ischaemic stroke population and the first to assess IQCODE/SVD progression. Future work should determine whether combining informant reports with imaging features of small vessel disease improves early detection of dementia.
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Mehndiratta, Prachi, Mohammad Wasay, and Man Mohan Mehndiratta. "Implications of Female Sex on Stroke Risk Factors, Care, Outcome and Rehabilitation: An Asian Perspective." Cerebrovascular Diseases 39, no. 5-6 (2015): 302–8. http://dx.doi.org/10.1159/000381832.
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Background: Stroke affects 16.9 million people annually and the greatest burden of stroke is in low- and middle-income countries, where 69% of all strokes occur. Stroke risk factors, mortality and outcomes differ in developing countries as compared to the developed world. We performed a literature review of 28 articles pertaining to epidemiology of stroke in Asian women, stroke risk factors, gender-related differences, and stroke outcomes. Summary: Asian women differ from women worldwide due to differences in stroke awareness, risk factor profile, stroke subtypes, and social issues that impact stroke care. While Asian men have a higher incidence of stroke as compared to women overall, the long- and short-term outcomes in Asian women tend to be poorer. Both conventional and gender-specific risk factors contribute to stroke risk. Oral contraceptive use and addictions such as tobacco and alcohol are less prevalent among Asian women due to socio cultural differences. There is however, a much higher preponderance of pregnancy-related stroke and cardio-embolic stroke secondary to rheumatic heart disease and heavy use of chewing tobacco. The overall outcome is poor due to poor access to health care and lack of resources. Key Messages: Our review exposed the gaps in our knowledge about stroke risk factors and differences in stroke care provided to Asian women. While there are sociocultural barriers that impede the provision of immediate care to these stroke patients, much needs to be done by way of prevention of recurrent stroke and treatment of risk factors.
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Nakagawa, Ichiro, Masashi Kotsugi, HunSoo Park, et al. "Lipid Core Burden Index Assessed by Near-Infrared Spectroscopy of Symptomatic Carotid Plaques: Association with Magnetic Resonance T1-Weighted Imaging." Cerebrovascular Diseases 50, no. 5 (2021): 597–604. http://dx.doi.org/10.1159/000516888.
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<b><i>Introduction:</i></b> Vulnerable plaques are a strong predictor of cerebrovascular ischemic events, and high lipid core plaques (LCPs) are associated with an increased risk of embolic infarcts during carotid artery stenting (CAS). Recent developments in magnetic resonance (MR) plaque imaging have enabled noninvasive assessment of carotid plaque vulnerability, and the lipid component and intraplaque hemorrhage (IPH) are visible as high signal intensity areas on T1-weighted MR images. Recently, catheter-based near-infrared spectroscopy (NIRS) has been shown to accurately distinguish LCPs without IPH. This study aimed to determine whether the results of assessment of high LCPs by catheter-based NIRS correlate with the results of MR plaque imaging. <b><i>Methods:</i></b> We recruited 82 consecutive symptomatic carotid artery stenosis patients who were treated with CAS under NIRS and MR plaque assessment. Maximum lipid core burden index (max-LCBI) at minimal luminal areas (MLA), defined as max-LCBI<sub>MLA</sub>, and max-LCBI for any 4-mm segment in a target lesion, defined as max-LCBI<sub>AREA</sub>, were assessed by NIRS. Correlations were investigated between max-LCBI and MR T1-weighted plaque signal intensity ratio (T1W-SIR) and MR time-of-flight signal intensity ratio (TOF-SIR) in the same regions as assessed by NIRS. <b><i>Results:</i></b> Both T1W-SIR<sub>MLA</sub> and T1W-SIR<sub>AREA</sub> were significantly lower in the high LCP group (max-LCBI &#x3e;504, <i>p</i> &#x3c; 0.001 for both), while TOF-SIR<sub>MLA</sub> and TOF-SIR<sub>AREA</sub> were significantly higher in the high LCP group (<i>p</i> &#x3c; 0.001 and <i>p</i> = 0.004, respectively). A significant linear correlation was present between max-LCBI<sub>MLA</sub> and both TIW-SIR<sub>MLA</sub> and TOF-SIR<sub>MLA</sub> (<i>r</i> = −0.610 and 0.452, respectively, <i>p</i> &#x3c; 0.0001 for both). Furthermore, logistic regression analysis revealed that T1W-SIR<sub>MLA</sub> and TOF-SIR<sub>MLA</sub> were significantly associated with a high LCP assessed by NIRS (OR, 44.19 and 0.43; 95% CI: 6.55–298.19 and 0.19–0.96; <i>p</i> &#x3c; 0.001 and = 0.039, respectively). <b><i>Conclusions:</i></b> A high LCP assessed by NIRS correlates with the signal intensity ratio of MR imaging in symptomatic patients with unstable carotid plaques.