Cerebrovascular Strokes During Venoarterial Extracorporeal Membrane Oxygenation

This study aimed to analyze the characteristics of carotid artery calcification (CAC) in stroke and nonstroke patients using computed tomography angiographic (CTA) and panoramic images. This is a retrospective study on patients who acquired both CTA and panoramic images at the Neurology Department of Kyungpook National University Hospital, Daegu, South Korea, between 2011 and 2016. The patients were divided into stroke (n = 109) and nonstroke (n = 355) groups based on the final diagnosis. CAC was analyzed in each group based on its presence, shape, and severity using the [Formula: see text]2 test. The differences in age and sex between the two groups were examined using a two-sample t-test. A measure of intraobserver reliability was obtained using Cohen's κ index. CAC was more frequently observed in the stroke group than in the nonstroke group using both CTA (stroke group, 100%; nonstroke group, 23.1%) and panoramic (stroke group, 83.5%; nonstroke group, 16.6%) images. Although scattered CAC shape and mild severity occupied the largest portion in both groups, vessel-outlined CAC was more common in nonstroke patients than in stroke patients. In age and sex analyses, only females patients in their 70 s showed significant differences in CAC shape between the stroke and nonstroke groups. On both CTA and panoramic images, although CAC is found more frequently in the stroke group, vessel-outlined-shaped CAC in the nonstorke group shows significant differences compared to other shapes.

Medical Management of Traumatic Vertebral Artery Injury Is Safe Regardless of the Severity of Injury

BackgroundIt is well known that the thrombus triggering stroke in patients with atrial fibrillation (AF) mainly comes from the left atrial appendage (LAA). This study aims to characterize the morphological and hemodynamic parameters and evaluate their differences between AF patients with and without a stroke history.MethodsCardiac CT images were obtained from AF patients with (n = 10) and without a history of stroke (n = 10). 3D models of the left atrium (LA) were reconstructed by processing the CT image, and the LA/LAA morphological parameters were measured. Computational fluid dynamics (CFD) simulations were performed to calculate the hemodynamic parameters in LA. The species-transport model and discrete phase model (DPM) were applied to analyze blood residual ratio and particle residual ratio, two qualitative parameters for thrombus formation and flow-out potential, respectively.ResultsThere were significant differences in LAA actual depth (p = 0.002), and direct length (p = 0.049) between the non-stroke and stroke groups. Significant differences were also found in certain hemodynamic parameters. The blood residual ratio in LAA was significantly smaller in the stroke group than in the non-stroke group (p < 0.05). Moreover, the particle residual ratio within LAA was significantly smaller in the stroke groups than in the non-stroke group (p < 0.05).ConclusionThere are significant differences in both morphological and hemodynamic parameters between AF patients with and without a stroke history. A high blood residual ratio in LAA confirms that thrombus is more likely to form in AF patients. A significantly smaller particle residual ratio in the stroke group may suggest the thrombus formed with LAA is more likely to flow out of LAA, leading to a higher risk of stroke. The proposed morphological and hemodynamic parameters may be additional risk factors that can be used to better risk stratify AF patients.

The mechanisms underlying ischemic infarction in patients with vertebrobasilar dolichoectasia (VBD) remain unclear. In this study, we retrospectively analyzed the imaging characteristics of high‐resolution magnetic resonance imaging (HR‐MRI) in patients with VBD to explore the possible mechanisms of ischemic stroke (IS) in patients with VBD. Patients with VBD were recruited from the HR‐MRI database between July 2017 and June 2021. HR‐MRI was used to evaluate the diameter, bifurcation height, laterality, arterial dissection, and atherosclerotic plaques of the basilar artery (BA). Transcranial Doppler was used to measure the vertebrobasilar mean velocity (Vm), peak systolic velocity (Vs), end‐diastolic velocity (Vd), and pulsatile index. Twenty‐six patients with VBD were enrolled, of which 15 had IS and 11 did not. The incidence of classical vascular risk factors, including age, sex, hypertension, diabetes, and hypercholesterolemia, did not differ significantly between the two groups. The BA diameters of the stroke group were significantly higher than that of the nonstroke group (6.57 ± 1.00 mm vs. 5.06 ± 0.50 mm, p = 0.000). The height of the BA bifurcation in the stroke and nonstroke groups was statistically significant (p = 0.002). Compared with the nonstroke group, the Vm, Vs, and Vd of the BA in the stroke group were lower, but the difference was not significant. In the 16 patients with atherosclerotic stenosis, 30 atherosclerotic plaques were found in the BA, 18 (60%) in the greater curvature, and 12 (40%) in the lesser curvature. In addition, one artery dissection (on the lesser curvature) and two dissecting aneurysms (on the greater curvature) were found in the BA of three patients, respectively. The BA diameter and bifurcation height are factors related to IS in patients with VBD. The mechanism of stroke in patients with VBD may involve abnormal hemodynamics, artery dissection, and atherosclerosis. HR‐MRI is a useful method for evaluating the risk and underlying mechanism of stroke in patients with VBD.

Analysis of Traumatic Vertebral Artery Injury Outcomes: Medical Management Is Safe Despite Severity of Injury

Background Chronic pain is common following stroke, yet its characteristics are poorly understood. Objectives To characterize the beliefs and perceptions of people with stroke who experience chronic pain and compare these to a non-stroke population with chronic pain. Method An online survey of the Pain Beliefs and Perceptions Inventory for stroke and non-stroke individuals with chronic pain. Pain beliefs and perceptions, including perceived causes of pain, were compared across the two groups. Results A total of 223 participants completed all questions. The stroke group (N = 106) reported significantly higher pain intensities (p = <0.001) than the non-stroke group (N = 117). In addition, they identified the stroke as the primary cause of their pain, whereas the non-stroke group identified a body injury as the primary cause. When compared to the non-stroke group, people with stroke were more likely to report their pain as being constant (p = <0.001), demonstrate a lack of understanding regarding cause(s) of their pain (p = <0.001), believe less that their actions contribute to their pain (p = <0.001), and have greater belief that their pain is permanent (p = <0.001). Conclusion These findings emphasize differences in the beliefs and perceptions associated with pain after stroke, supporting the value of targeted attention from research and therapy perspectives. Significant differences in the pain experienced by stroke and non-stroke groups may reflect a poor understanding of chronic pain following stroke. Future educational programs for stroke survivors should be tailored. Targets for future educational interventions are identified and include causes of pain, an understanding of its behavior and potential for improved prognosis.

BackgroundPatients with left atrial myxoma and concomitant ischemic stroke continue to face a significant risk of recurrent cerebral embolism. However, the safety and feasibility of cardiopulmonary bypass (CPB) surgery within 3 months post-stroke remain unclear. This study aims to investigate the safety and clinical outcomes of early surgical intervention in this high-risk cohort.MethodsWe conducted a retrospective analysis of 364 patients who underwent surgical resection of left atrial myxoma at the Second Xiangya Hospital between 2011 and 2024. Patients were stratified into two cohorts based on the presence or absence of preoperative ischemic stroke: an ischemic stroke group (n = 66) and a non-stroke group (n = 298). Within the ischemic stroke cohort, patients were further divided into three subgroups based on the time interval between stroke onset and cardiac surgery: early (1–30 days), intermediate (31–90 days), and late (> 90 days). Preoperative conditions, comorbidities, stroke timing, brain infarct locations, neurological symptoms, and postoperative neurological recovery were evaluated. The National Institutes of Health Stroke Scale (NIHSS) was used to assess stroke severity. The modified Rankin Scale (mRS) was used to assess neurological recovery.ResultsAmong the 364 patients, 66 (18.1%) had preoperative ischemic stroke. There were no in-hospital deaths in either the ischemic stroke or non-stroke groups. Postoperative neurological deterioration was not observed in the ischemic stroke group. The NIHSS was used to assess 40 out of 66 patients with ischemic stroke, all of whom had scores ≤ 20. In the early subgroup, 17 out of 25 ischemic stroke patients (68%) achieved full neurological recovery; in the intermediate subgroup, 13 out of 18 patients (72.2%) recovered fully; and in the late subgroup, 16 out of 23 patients (69.6%) achieved full recovery. Long-term survival was not significantly different between the two groups or among the three subgroups.ConclusionEarly surgical intervention in patients with left myxoma complicated by preoperative ischemic stroke does not lead to significantly worse postoperative outcomes. Early cardiac surgery may be considered for patients without very severe ischemic stroke.

Introduction: Patients with non-valvular atrial fibrillation (NVAF) and previous stroke are at significantly higher risk of stroke recurrence. Data on the efficacy of left atrial appendage closure (LAAC) on these patients is limited. The aim of this study was to investigate the differences of LAAC efficacy on long-term cardio- and cerebrovascular outcomes in NVAF patients with vs. without prior stroke.Methods: Three hundred and seventy consecutive NVAF patients who underwent LAAC were enrolled and divided into stroke and non-stroke groups based on history of previous stroke. Endpoints, such as thromboembolism, major bleeding, and mortality post-LAAC, were followed up among groups.Results: Patients in the stroke group had higher mean CHA2DS2-VASc and HAS-BLED scores compared to the non-stroke group (5.1 vs. 3.6 and 4.1 vs. 3.4, both P < 0.001, respectively). Over a median follow-up of 2.2 years, there were no significant differences in incidence rates of thromboembolism, device-related thrombus (DRT), major bleeding, and combined efficacy endpoints between the two groups. In both stroke and non-stroke groups, LAAC decreased the risk of thromboembolism [relative risk reduction (RRR) 87.5%, P = 0.034, and 74.6%, P = 0.004, respectively] and major bleeding (RRR 68.8%, P = 0.034, and 68.6%, P = 0.007, respectively) compared with predicted risk. The RRR in thromboembolism was greater in patients with vs. without prior stroke (OR 2.45, 95% CI: 1.20–5.12, P = 0.016). The incidence rates of all-cause mortality and non-cardiovascular death were similar between the two groups, but the risks of cardiovascular death post-LAAC both before (1.4% vs. 8.1%, respectively, P = 0.038) and after adjustment for confounding factors (P = 0.048) were significantly decreased in the stroke group.Conclusions: Patients with vs. without prior stroke did not exhibit a worse clinical prognosis after LAAC. LAAC may provide an increased benefit in cardio-cerebrovascular outcomes in patients with previous stroke compared to those without previous stroke. Further research is necessary to evaluate the efficacy of LAAC in this field.

ObjectiveTo investigate the risk factors for ischemic stroke in elderly patients with hypertension and type 2 diabetes mellitus.MethodsA total of 112 elderly patients with hypertension and type 2 diabetes, treated at Jiangmen Central Hospital from January 2023 to December 2023, were selected and categorized into a stroke group and a non-stroke group, each comprising 56 patients. The two groups were examined for demographic data, risk variables were evaluated by multifactorial logistic regression analysis, and the predictive value was determined using ROC curves.ResultsThe comparison of hyperhomocysteinemia (HHcy), fibrinogen (FIB), and high-density lipoprotein cholesterol (HDL-C) between the non-stroke and stroke groups revealed statistically significant differences (P < 0.05). Logistic regression analysis indicated that HHcy (OR 16.936; 95% CI 1.946–146.071; P = 0.010), FIB (OR 1.773; 95% CI 1.238–2.540; P = 0.002), and HDL-C (OR 0.182; 95% CI 0.043–0.775; P = 0.021) were significant factors in the onset of ischemic stroke among elderly patients with hypertension and type 2 diabetes. ROC curve analysis revealed that the area under the curve (AUC) for FIB, HDL-C, and HHcy in diagnosing stroke associated with hypertension and type 2 diabetes mellitus in the elderly were 0.704, 0.640, and 0.598, respectively, while the AUC for the combined diagnosis of all three was 0.784.ConclusionsHHcy, FIB, and HDL-C independently influence the occurrence of ischemic stroke in elderly patients with hypertension combined with type 2 diabetes mellitus, and their combined enhanced predictive capability for ischemic stroke occurrence.

Objective To investigate the relationship between carotid plaque stability characteristics and ischemic stroke risk using computed tomography angiography (CTA), with a focus on differences between embolic stroke of undetermined source (ESUS) and non-ESUS cases. Methods This retrospective study included 173 patients with carotid plaques who underwent extracranial carotid CTA. Patients were categorized into stroke and non-stroke groups, with the stroke group further divided into ESUS and non-ESUS subgroups. Plaque features including stenosis severity, plaque type, ulceration, intraplaque hemorrhage (IPH), and lipid-rich necrotic core (LRNC) were assessed. Clinical information was also collected to examine the connection between carotid plaque characteristics and stroke risk. Results Compared to the non-stroke group, the stroke group had a higher proportion of male patients, elevated total cholesterol levels, greater stenosis severity, along with higher frequencies of plaque ulceration, calcification, IPH, and LRNC. Also, the maximum soft and total plaque thickness were greater, while maximum hard plaque thickness was lower. Multivariate logistic regression identified male gender, stenosis severity, LRNC, and maximum soft plaque thickness as independent risk factors. Among stroke patients, the ESUS group exhibited a higher prevalence of non-stenotic plaques (stenosis <50%), along with significantly increased IPH, plaque calcification, and adventitial calcification, compared to the non-ESUS group. Conclusion CTA-based assessment of carotid plaque features enables effective evaluation of stroke risk. Notably, vulnerable plaques with non-severe stenosis may contribute to the pathogenesis of ESUS, underscoring the need for plaque composition analysis beyond luminal narrowing.

ObjectiveTo evaluate the association between clinical and socio-demographic status and health-related quality of life (HR-QoL) in stroke survivors age 40 and older in the Korean population.MethodsThe relationship between stroke and HR-QoL was investigated using data from the Korea National Health and Nutrition Examination Survey (KNHANES), conducted from 2007–2012. The total number of respondents was 24,050 and 757 stroke survivors were included. Specifically, we investigated factors associated with the lowering of HR-QoL in a group of Korean adult stroke patients age 40 and older after adjusting for socio-demographic factors, anthropometric measurements, and clinical comorbidities. Adjusted effects of covariates on EuroQol-visual analog scales (EQ-VAS) scores were estimated with a complex-samples general linear model and multivariate-adjusted odds ratios of the lowest quintile versus highest quintile of the EQ-VAS scores in the stroke group were estimated with a complex-samples logistic regression model.ResultsSocio-demographic, anthropometric factors, and clinical comorbidities significantly differed between the stroke and non-stroke groups, except regarding gender and residential area. The EQ-VAS was significantly lower in the stroke than non-stroke group. Anxiety/depression problems significantly lowered EQ-VAS, as did low education level, smoking, mobility and usual activities problems. Also, aging in 1-year increments and cardiovascular disease had a significant effect on lower EQ-VAS in stroke survivors.ConclusionPeople with a stroke have significantly lower HR-QoL than healthy subjects. Therefore, managing depression, smoking, or cardiovascular disease and maintenance of physical function may be priority goals in improving HR-QoL after a stroke.

Introduction: Atrial fibrillation (AF) patients are at high risk of stroke with ~90% clots originating from the left atrial appendage (LAA). Studies correlating left atrial (LA) and LAA geometrical parameters with stroke exhibit conflicting results. Also, blood-flow based parameters and their association with stroke for AF patients remains unexplored. Hypothesis: Low blood-flow in the LA/LAA is associated with stroke for AF patients. Methods: We retrospectively collected CT images of 53 AF patients and dichotomized them based on clinical event into stroke and non-stroke groups. After image segmentation to obtain 3D LA geometry, personalized blood-flow analysis was performed to model LA hemodynamics. For geometry, we calculated area of 4 pulmonary veins (PVs) and area and volume of LA/LAA. For hemodynamics, we quantified blood flow velocity, wall shear stress (WSS, blood-friction on LA wall), oscillatory shear index (OSI, directional change of WSS) and endothelial cell activation potential (ECAP, ratio of OSI and WSS quantifying slow and oscillatory flow) in LA/LAA. All parameters were compared between the groups. Results: Twenty-seven patients were included in the stroke and 26 in the non-stroke group. Geometrically, there was non-significant difference between the LA/LAA area and volume, and area of PVs between the groups (Figure A). In terms of blood-flow (Figure B), velocity, WSS, OSI and ECAP in the LA had non-significant differences between the groups. However, stroke group had significantly lower velocity, WSS and higher ECAP in LAA as compared to non-stroke group. This suggests that stroke patients had slow and oscillatory circulating blood-flow in the LAA, exposing it to thrombogenesis, potentially causing stroke. Conclusion: Slow and oscillatory flow in the LAA alone is associated with stroke in this AF cohort. Personalized blood-flow analysis can identify such hemodynamic conditions, aiding in clinical stroke risk stratification of AF patients.

BackgroundRecent evidence has shown that the pathogenesis of ischaemic stroke associated with atrial fibrillation (AF) is complex and involves other factors in addition to arrhythmias. The purpose of this study was to investigate the relationship among AF, CHA2DS2-VASc score and ischaemic stroke in patients with coronary artery disease (CAD) in Hebei, China.MethodsA total of 2,335 patients with CAD from September 2016 to May 2019 at the Second Hospital of Hebei Medical University were included (mean age 62.73 ± 10.35 years, range 26–92 years; 41.58% female). This was a cross-sectional study, and participants were divided into non-stroke (n = 1997) and ischaemic stroke groups (n = 338). Propensity score matching (PSM) was performed to match ischaemic stroke patients with non-stroke patients in a 1:4 ratio. The relationship among AF, the CHA2DS2-VASc score and ischaemic stroke was evaluated using univariable generalized linear models for different sex, age, body mass index (BMI), CAD and CHA2DS2-VASc score subgroups. Univariable and multivariable generalized linear models were used to evaluate the relationship between AF and ischaemic stroke in the different models.ResultsCompared with that in the non-stroke group, the prevalence of AF (8.81% vs. 14.20%, P = 0.002) in the ischaemic stroke group was higher. The proportion of patients with ischaemic stroke was significantly different between the AF group and the non-AF group (28.74% vs. 19.04%, P = 0.003). An increasing CHA2DS2-VASc score was associated with a gradual increase in the prevalence of AF (P for trend < 0.001). Subgroup analysis showed that the trend towards increased stroke risk in the AF group was consistent across the various subgroups. The multivariable analysis demonstrated that AF was not associated with ischaemic stroke compared with the absence of AF (OR = 1.55, 95% CI 0.94–2.56, P = 0.087).ConclusionIn our cross-sectional study, after adjustment for confounding factors, there was no association between AF and ischaemic stroke. The increased risk of ischaemic stroke associated with AF was attenuated by atherosclerotic factors. Our study supports the current view that enhanced control of modifiable cardiovascular risk factors in patients with AF is essential.

Background: Many studies have attempted to determine the incidence, predictors, and outcomes of cerebrovascular stroke after cardiac surgery, with different, sometimes contradictory, results because of differences in population risk profiles, study design, and surgical details. Methods: We retrospectively reviewed the records of all adult patients who underwent cardiac surgery between January 2018 and January 2023. Univariate, multivariable, and survival analyses were performed to identify the outcomes and predictors of ischemic and hemorrhagic strokes. Results: Of the 1334 patients studied, 70 (5.2%) patients had ischemic stroke, 23 (1.7%) had intracranial hemorrhage (ICH), and 9 (0.7%) had combined ischemic and hemorrhagic strokes. The patients who developed strokes had longer cardiopulmonary bypass (CPB) time (165.5 [126, 234] versus 136 [104, 171] min, p < 0.001) and aortic cross-clamping time (112 [79, 163] versus 89 [75, 121.5] min, p < 0.001), with higher rates of intra-aortic balloon pump (IABP) use (13.3% vs. 4.4%, p < 0.001), veno-arterial extracorporeal membrane oxygenation use (24.8% vs. 12.37%, p < 0.001), and mediastinal exploration for bleeding (22.9% vs. 8.9%, p < 0.0011). The patients who developed strokes showed increased hospital mortality (37.1% vs. 5.6%, p < 0.001), new need for dialysis (29.5% vs. 10.7%, p < 0.001), higher rate of tracheostomy (13.3% vs. 1.2%, p < 0.001), and longer intensive care unit (ICU) stay (12 [7, 28] versus 3 [2, 8] days, p < 0.001) and post-ICU stay (16 [7, 39] versus 5 [3, 10] days, p < 0.001). Follow-up for 36.4 (21.67, 50.7) months revealed an insignificant mortality difference, but there was an increased risk of recurrent cerebrovascular strokes. Cox-proportional hazards regression showed an increased risk of hospital mortality after cardiac surgery in patients who developed acute ischemic stroke (HR: 5.075, 95% CI: 3.28-7.851, p < 0.001) and ICH (HR: 12.288, 95% CI: 7.576-19.93, p < 0.001). Logistic multivariable regression showed that increased age, hyperlactatemia, redo cardiotomy, history of old stroke, CPB time, and perioperative IABP use were the predictors of ischemic stroke. Young age, old ICH, hyperlactatemia, and hypoalbuminemia were the predictors of postoperative ICH. Postoperative ICH, ischemic stroke, atrial fibrillation, chronic kidney disease, blood lactate level 24 h after surgery, and increased age were the independent predictors of mortality. Conclusions: Ischemic and hemorrhagic cerebrovascular strokes are serious complications that increase postoperative mortality and prolong hospitalization after cardiac surgery. Atrial fibrillation was not a significant predictor of postoperative stroke but was a predictor of hospital mortality. Careful attention should be given to maintaining hemodynamic stability and minimizing CPB time, especially in patients with a history of cerebrovascular strokes and redo cardiotomy.

Simple SummaryCardiac tumors are relatively rare. Cardiac Myxomas (CM) are considered one of the most common benign cardiac tumors. They are usually distinct from soft tissue myxoma, most often occurring as a solitary, sporadic, pedunculated mass in the left atrium, and approximately 10% are associated with Carney syndrome with a high recurrence rate. They may cause sudden death, usually due to mitral valve obstruction or congestive heart failure. Malignant changes are known to occur but are extremely rare. They may mimic malignant neoplasia because of frequent embolism and can cause neurological deficits before theirsurgical removal. The current study analyzed the outcomes after operative myxoma excision in patients with or without cerebral embolic events prior to excision.Background: Cardiac myxomas (CM) are the most common primary cardiac tumors in adults. They are usually benign; however, malignant changes are known to occur but are extremely rare. Embolization is a common complication of cardiac myxomas and can cause neurological deficits before their surgical removal. The current study analyzed the outcomes after operative myxoma excision in patients, with and without cerebral embolic events prior to excision. Methods: All 66 consecutive patients who underwent a surgical excision of CM between 2005 and 2019 at our department were analyzed retrospectively. Patients with (n = 14) and without (n = 52) preoperative strokes caused by cerebral tumor embolization were compared. Results: The mean age was 58.4 ± 12.7 years in the stroke group (SG) and 62.8 ± 11.7 years in the non-stroke group (N-SG) (p = 0.226). Gender (35.7% vs. 61.5% female; p = 0.084) did not differ significantly, and comorbidities were comparable in both groups. The left hemisphere in the territory of the middle cerebral artery was affected by preoperative cerebral infarction most commonly (28.6%). The time from diagnosis to cardiac surgery procedure was 7 (3–24) days in the SG and 23 (5–55) days in the N-SG (p = 0.120). Cardiac myxomas were localized in the left atrium in both groups more frequently (SG: 92.9% vs. N-SG: 78.8%; p = 0.436). In the SG, 57.1% of CM had a non-solid surface, were localized in the left heart, and had a pedunculated attachment away from the fossa ovalis. In the N-SG, 92.3% of CM did not meet all these criteria (p < 0.001). The maximal diameters of CM were comparable (SG: 3.4 ± 1.5 cm vs. N-SG: 3.8 ± 2.1 cm; p = 0.538). The operation times (192.5 (139.3–244.5) min vs. 215.5 (184.5–273.3) min; p = 0.046) and the cross-clamp times (54.5 (33.3–86.5) min vs. 78.5 (55–106.8) min; p = 0.035) were significantly shorter in the SG. Only in the N-SG were reconstructions of the endocardium with bovine pericardium required after resection (51.9% vs 0%; p < 0.001). In the N-SG, CM were explored via the right atrium more often (57.7% vs. 14.3%; p = 0.007). Patients in the N-SG required significantly shorter ICU care after surgery (p = 0.020). Other postoperative courses did not differ significantly. After tumor removal, 1.9% of the N-SG suffered their first stroke and 14.3% of the SG had a cerebral re-infarction (p = 0.111). The 30-day mortality rates were 1.9% in the N-SG and 7.1% in the SG (p = 0.382). In one case in the N-SG, a tumor recurrence was diagnosed. The Kaplan–Meiercurves showed a significantly better long-term prognosis for patients in the N-SG (p = 0.043). Conclusions: After the surgical removal of CM, the outcome is compromised if preoperative cerebral embolization occurs. Surgical treatment is therefore indicated as soon as possible, especially when CM have a non-solid surface, are localized in the left heart, and have a pedunculated attachment away from the fossa ovalis.