Absence Of Infarction Research Articles

Multidisciplinary approach to Patent Foramen Ovale (PFO) closure for Cryptogenic Stroke: Brain-Heart Board Experience (P11-5.024)

<h3>Objective:</h3> Our study evaluates the predictors of closure recommendation by multidisciplinary board for PFO closure and its impact on outcomes. <h3>Background:</h3> PFO closure in carefully selected patients is an effective secondary preventive strategy in young cryptogenic stroke patients which requires close collaborative approach. <h3>Design/Methods:</h3> Brain-Heart Board is comprised of vascular neurology and cardiology subspecialities. Adult patients referred to the board for consideration of PFO closure between October 2017 to March 2021 were included in this analysis. Demographics, comorbid conditions, infarct location, Risk of Paradoxical Embolism (RoPE) Score, event frequencies (recurrent TIA or stroke, intracranial hemorrhage (ICH), post-PFO closure cardiac arrythmias) and modified Rankin Scale (mRS at 1 year) were compared between the groups (PFO closure vs. medical management). Multivariable logistic regression was used to identify predictors of closure and chi-square tests to test differences in outcomes for patients according to management. <h3>Results:</h3> 270 patients (229 stroke; 41 TIA) were included in the analysis. 119 (44%) patients were recommended for PFO closure of which 117 (98%) had infarct on neuroimaging. Age and RoPE score were similar in closure and medical management cohorts (age; 50±12 vs. 52±13, p&gt;0.05 RoPE 4±3 vs. 6±2 p&gt;0.05). In multivariable analysis, absence of infarct on neuroimaging was an independent predictor of medical management recommendation by the board (OR 0.05 95% CI 0.01–0.19 p&lt;0.05). Event frequency was low in both cohorts (5.9% vs. 4.8% p&gt;0.05) and were comprised primarily of cardiac arrhythmias (6 atrial fibrillation and 1 ICH in Closure group; 1 TIA and 1 recurrent stroke in medical management group). Excellent functional outcome (mRS 0–1) was similar in both cohorts (66% vs. 71% p&gt;0.05) at 1 year. <h3>Conclusions:</h3> Multidisciplinary approach towards PFO closure results in low frequency of complications (recurrent ischemic stroke, ICH and post-PFO closure cardiac arrythmias) and good outcomes. Infarct on neuroimaging predicts closure recommendation by the multidisciplinary board. <b>Disclosure:</b> The institution of Dr. Khan has received research support from NINDS. The institution of Dr. Khan has received research support from Genentech. The institution of Dr. Khan has received research support from Spectrum Health-MSU alliance. Dr. Khan has received research support from NIH. Dr. McCarthy has nothing to disclose. Dr. Haggerty has nothing to disclose. Dr. Min has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Abbott . Dr. Min has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Medtronic . Dr. Miller has nothing to disclose. Dr. Tsai has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Cerenovus. Dr. Merhi has nothing to disclose. Dr. Berkompas has received personal compensation in the range of $10,000-$49,999 for serving as a Proctor and consultant with Medtronic. Dr. Wees has nothing to disclose. Dr. Khan has nothing to disclose. Dr. Ahrar has nothing to disclose. Mrs. Evans has nothing to disclose. Dr. Dahu has nothing to disclose. Dr. Gauri has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Medtronic . Dr. Gauri has received personal compensation in the range of $5,000-$9,999 for serving on a Speakers Bureau for Atricure . Mrs. Moelker has nothing to disclose. Dr. Chalfoun has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Medtronic. Dr. Chalfoun has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Atricure. Dr. Chalfoun has received personal compensation in the range of $5,000-$9,999 for serving on a Speakers Bureau for Atricure.

Abstract Number ‐ 89: Left M1 occlusion rescued by the Recurrent artery of Huebner: a spectrum of MCA collaterals

Introduction Proximal MCA occlusion has variable presentation and clinical course, ranging from MCA syndrome with completed infarct at presentation to asymptomatic, discovered incidentally on imaging. This variability is likely dictated by variable collateral circulation that ultimately fails on variable time courses. For discussion we can divide these into (1) rapid progressors, (2) standard, (3) slow progressors, (4) situationally symptomatic, and (5) asymptomatic. There is clear evidence for the role of endovascular therapy for those who are significantly symptomatic and progress along an acute timeline when combined with imaging criteria (1 and 2), but there is no clear guidance for those patients who progress slowly or are minimally symptomatic (3‐5). Methods We present selected cases of patients with left MCA occlusion from groups 3–5 along with their presentation and collateral flow as assessed by non‐invasive imaging and DSA. Results Case 1. Slow Progressor. A 63‐year‐old woman with past occipital lobe strokes presented with progressive aphasia of insidious onset that began at some point the previous day. NIHSS 4 for aphasia and LOC questions. Initial CTA revealed a left M1 occlusion with ASPECTS 9. Despite low NIHSS and extended time to LKW, she was brought to the angiography suite. Initial angiogram confirmed M1 occlusion with extensive collateralization via the left ACA and anterior temporal artery, but no reconstitution of the MCA proper. Thrombectomy was completed with TICI2B recanalization. Followup MRI revealed minimal infarct in the left insula. The patient was discharged with an NIHSS of 1 for a baseline hemianopia not appreciated on initial exam. Case 2. Situationally Symptomatic. A 55‐year‐old man with symptomatic epilepsy from bilateral subdural hygromas was admitted for video EEG monitoring of episodic dizziness and word‐finding difficulty. Initial exam revealed only orthostatic light‐headedness. Further history revealed these events often happed at night upon standing. No epileptiform events were captured. MRA revealed a complete occlusion of the proximal M1 with reconstitution at the M2 bifurcation in the sylvian fissure. Given lack of persistent clinical deficit and absence of infarct on MRI, DSA was deferred. The patient is followed outpatient without further symptom progression. Case 3. Asymptomatic. A 38 year‐old‐man with TBI presented to the emergency department with thunderclap headache. Initial exam was without deficits. CTA and MRA revealed complete occlusion of the left MCA. We proceeded to the angiography suite where DSA revealed complete left M1 occlusion with distal reconstitution at the M2 bifurcation primarily via the Recurrent Artery of Huebner in addition to ACA collaterals. Lumbar puncture was benign and his headache responded completely to typical migraine treatment. The patient was discharged to outpatient follow up without further sequalae. Conclusions We present a series of illustrative cases of patients with MCA occlusion of variable collateral supply and clinical course, none of whom met conventional criteria for endovascular intervention. More research is needed to establish clinical and imaging criteria to separate patients who would benefit from endovascular intervention from those who are best managed medically in these scenarios.

Abstract TMP63: Structural Network Changes In Children With Moyamoya Disease Prior To Surgical Intervention

Purpose: Moyamoya disease/syndrome (MMD) is a progressive steno-occlusive disease involving the intracranial arterial circulation. Long term stenosis/hypoperfusion can lead to intellectual disability and cognitive impairment even in the absence of documented infarct. We aim investigate any underlying network abnormalities in MMD patients with no apparent ischemic injury. Materials and Methods: We retrospectively reviewed children with MMD with normal appearing parenchyma on conventional MRI. Control patients were selected from our existing database. Clinical, surgical and demographic data, including degree of stenosis as measured semi-quantitatively on MRA, were collected. Patients with documented infarcts, low quality DTI, and NF1 were excluded from the analysis. Group and correlational connectometry with degree of stenosis were performed. Results: A total of 28 patients were reviewed with 16 patients included in the study. Median (and interquartile range) age was 10.5 (8.5 - 13.5). Between group connectometry analysis identified infratentorial and supratentorial decreased connectivity in patients compared to controls, specifically in: middle cerebellar peduncle, corpus callosum, right parietopontine tract, superior cerebellar peduncle, left inferior fronto-occipital fasciculus. (Figure 1) In addition, we found negative correlation between the degree of stenosis and structural connectivity of multiple white matter pathways. Conclusion: Our findings reveal abnormal structural connectivity in children with MMD in the absence of infarcts on conventional MRI. Connectomics offers a unique opportunity to study the effect of long-term stenosis/hypoperfusion on cerebellar-cerebral networks and provide new insights into the mechanism of the structural plasticity/reorganization in these patients before bypass surgery. Future research is needed to determine longitudinal network changes before and after surgery.

Abstract TP186: Multidisciplinary Approach To Patent Foramen Ovale (pfo) Closure For Cryptogenic Stroke: Brain-heart Board Experience

Background: The prevalence of PFO is up to 40% in patients with cryptogenic stroke and TIA suggesting paradoxical embolism. PFO closure in carefully selected patients is an effective secondary preventive strategy in these patients. We report predictors of closure recommendation by multidisciplinary board for PFO closure and its impact on outcomes. Methods: Brain-Heart Board is comprised of vascular neurology, cardiology subspecialities (structural, electrophysiology and cardiac imaging). Adult patients referred to the board for consideration of PFO closure between October 2017 to March 2021 were included in this analysis. Demographics, comorbid conditions, infarct location, Risk of Paradoxical Embolism (RoPE) Score, event frequencies (recurrent TIA or stroke, intracranial hemorrhage (ICH), post-PFO closure cardiac arrythmias) and modified Rankin Scale (mRS at 1 year) were compared between the groups (PFO closure vs. medical management). Multivariable logistic regression was used to identify predictors of closure and chi-square tests to test differences in outcomes for patients according to management. Results: The board discussed 270 patients (229 stroke; 41 TIA). 119 (44%) patients were recommended for PFO closure of which 117 (98%) had infarct on neuroimaging. Age and RoPE score were similar in closure and medical management cohorts (age; 50±12 vs. 52±13, p&gt;0.05 RoPE 4±3 vs. 6±2 p&gt;0.05). In multivariable analysis, absence of infarct on neuroimaging was an independent predictor of medical management recommendation by the board (OR 0.05 95% CI 0.01-0.19 p&lt;0.05). Event frequency was low in both cohorts (5.9% vs. 4.8% p&gt;0.05) and were comprised primarily of cardiac arrhythmias (6 atrial fibrillation and 1 ICH in Closure group; 1 TIA and 1 recurrent stroke in medical management group). Excellent functional outcome (mRS 0-1) was similar in both cohorts (66% vs. 71% p&gt;0.05) at 1 year. Conclusion: Multidisciplinary approach for selecting patients for PFO closure results in low frequency of complications (recurrent ischemic stroke, ICH and post-PFO closure cardiac arrythmias) and good outcomes. Presence of infarct on neuroimaging predicts closure recommendation by the multidisciplinary brain-heart board.

Correlation between Microalbuminuria and Coronary Angiographic Severity in Non-diabetic Myocardial Infarction patients

Background: Microalbuminuria may have an association with myocardial infarction in absence of traditional risk factors like diabetes. The present study was intended to find the association between microalbuminuria and angiographic severity of coronary artery disease in non-diabetic myocardial infarction patients. Methods: This cross sectional analytical study included 105 non-diabetic patients with myocardial infarction who underwent coronary angiography (CAG). The microalbuminuria was defined as urine albumin to creatinine ratio (ACR) of 30 -300 mg/g, while angiographic severity was measured by Gensini score with score e” 36 was taken as moderate to severe coronary artery disease (Group I) and score below 36 was termed as absent or mild coronary artery disease (Group II). Association of microalbuminuria with severity of coronary artery disease was determined. Results: Presence of microalbuminuria was found significantly higher (45%) in patients with moderate to severe coronary artery disease than that in patients with absent or mild CAD (4.6%). The Odds of having moderate to severe coronary artery disease in patients with microalbuminuria was observed to be 17 times (95% CI = 4.5 - 63) higher than that in patients without having this condition. Correlation between ACR and Gensini score was also found a significant positive relationship (r=0.702, p&lt;0.001) with 70% of variation in Gensini score being explained by ACR. Conclusion: Microalbuminuria can be considered as a predictor of the severity of coronary artery disease in non-diabetic myocardial infarction patients. Cardiovasc j 2022; 15(1): 56-62

Various tests of left neglect are associated with distinct territories of hypoperfusion in acute stroke.

Hemispatial neglect is among the most disabling consequences of right hemisphere stroke. However, there is no consensus on the optimal assessments to identify neglect. We hypothesized that different tests for neglect given the same day (i) detect distinct aspects and types of neglect, (ii) are sensitive to different cognitive functions (beyond spatially specific processing) and (iii) are associated with distinct regions of hypoperfusion. We examined data from 135 participants with acute, right-hemispheric ischaemic stroke who received an MRI and neglect testing within 48 h of acute infarct in a cross-sectional study. The volume of infarct was calculated on diffusion-weighted imaging. We also scored severity and location of fluid-attenuated inversion recovery hyperintense vessels in six areas (anterior cerebral artery territory, posterior cerebral artery territory and four within the middle cerebral artery territory) to estimate the volume and location of hypoperfusion in acute stroke. Neglect tests included gap detection, scene copy, line bisection, line cancellation, oral reading and picture description. We found strong correlations between tests that evaluated viewer-centred processing, as well as strong correlations between tests that evaluated stimulus-centred processing. The error rate on different tests was associated with hypoperfusion in different vascular territories, even after controlling for the volume of an infarct. Our results confirm that it is essential to administer a battery of different tests of hemispatial neglect to capture various deficits in attention and spatially specific processing that underlies neglect. Our results also show the potential usefulness of hyperintense vessel ratings as an indication of dysfunction beyond the infarct, as the ratings (and not infarct volume) were highly associated with many clinical deficits. Finally, results underscore that diverse types of neglect are clinically important in acute stroke, as they reflect different areas of hypoperfused tissue, which may be salvageable in the absence of infarct in those areas. As such, neglect batteries may be useful for detecting patients with cortical hypoperfusion who are candidates for reperfusion therapies.

Cardiac magnetic resonance strain and mechanical dispersion assessment in patients with chronic total coronary artery occlusion

Abstract Background Chronic total occlusions (CTO) are a frequent angiographic finding. Viability of CTO-subtended myocardium is dependent on the presence of an adequate collateral circulation. At rest, collateral supply may be sufficient to avert ischaemia and maintain normal systolic function. However, it remains unclear whether CTO-subtended myocardium may be considered truly normal, or whether subtle functional abnormalities may be present at rest. Purpose To determine whether, in the absence of infarction and hibernation, CTO-subtended myocardium remains functionally normal or whether abnormalities of strain and/or mechanical dispersion may be present at rest. Methods In a retrospective, single centre, observational study, we studied patients with ≥1 angiographically-diagnosed CTO referred for clinical stress perfusion cardiovascular magnetic resonance (CMR), and compared healthy volunteers (HVs) with a normal stress CMR scan. CMR imaging comprised functional and scar assessment with qualitative [visual] evaluation of infarction and segmental wall motion. Patients with infarction and/or wall motion score index (WMSI) ≥1 were excluded from further analysis. In remaining CTO subjects and HVs, segmental peak systolic longitudinal strain and circumferential strain were analysed (in 3 long-axis planes and 3 short-axis planes, respectively) and mechanical dispersion for both orientations was computed. Image analysis was performed using Medis (QStrain) software blinded to all clinical information. Results From a total of 389 patients with ≥1 angiographically-diagnosed CTO, 68 had normal WMSI and no infarction (63.0±11.7 years, 79.4% male, LVEF 62.6±4.5%). Fifty HVs (61.1±7.0 years, 74.0% males, LVEF 61.1±5.3%) were also studied. The majority of CTO patients had concomitant coronary artery disease in at least one non-CTO vessel (n=37, 54.4%). GLS was lower in CTO patients than HVs (−21.8%±1.5% versus −24.0±1.1%; p&amp;lt;0.0001; Figure 1). By contrast, GCS was greater in CTO patients (−32.7±2.5% versus −28.8±2.1%; p&amp;lt;0.0001). Mechanical dispersion was increased in CTO patients (Figure 2), both longitudinally (90.3±14.6 ms in CTO patients versus 68.6±11.1 ms in HVs; p&amp;lt;0.0001) and circumferentially (66.7±9.1 ms versus 55.3±6.6 ms, respectively; p=0.02). Conclusion Subclinical changes in left ventricular dynamics are present at rest in CTO patients with fully viable myocardium and no evidence of resting regional wall abnormality. Further study is warranted to evaluate the potential association between mechanical dispersion and arrhythmic events in CTO. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): NIHR Clinician Scientist Award (CS-2018-18-ST2-007 to J.R.A.) and Research Professorship award (RP-2017-08-ST2-007 to G.P.M.). Figure 1. Strain analysis. CTO vs HVFigure 2. Mechanical dispersion. CTO vs HV

Abstract 59: Presence of Infarct Predicts Recurrence and Efficacy of Dual Antiplatelet Therapy: A Post-Hoc Analysis of the POINT Trial

Background: The combination of aspirin and clopidogrel for 90 days after minor stroke or transient ischemic attack (TIA) reduced the risk of recurrent stroke in the POINT trial. The risk reduction was greater in patients with infarct on CT or MRI compared to those without infarct. Objective: To investigate the effect of DAPT on minor stroke and TIA in the POINT trial based on (1) the presence or absence of infarct attributed to the index event (“index infarct”) and (2) whether the index event was classified as stroke or TIA. Design/Methods: Patients were divided into two groups based on whether they had an “index infarct” or not. Baseline demographics and clinical variables were compared between groups using standard statistical tests. We used univariate and multivariable cox-regression models to determine associations between presence of infarct on imaging and primary and secondary outcomes, and interaction analyses to determine whether the presence of “index infarct” modifies the effect of DAPT on study outcomes. We also explored whether the association of “index-infarct” with primary and secondary outcomes varied by index diagnosis (TIA vs. minor stroke). Results: Amongst 4881 enrolled in POINT, 4876 patients had data on whether there was an “index-infarct”; 1793 (36.8%) had “index-infarct”. In adjusted cox-regression analyses, the presence of “index infarct” was associated with the primary efficacy outcome (HR 3.02 95% CI 2.34-3.89, p &lt; 0.01) and subsequent ischemic stroke (HR 3.10 95% CI 2.39-4.02, p &lt; 0.01). The effect of DAPT vs. aspirin on primary efficacy outcome was more pronounced in patients with “index infarct” (HR 0.58 95% CI 0.43-0.79, p &lt;0.01) vs. those without (HR 1.16 95% CI 0.79-1.71, p=0.44) (p for interaction = 0.01). In a secondary analysis based on final diagnosis, the effect of “index infarct” on primary outcome was only significant in those with minor stroke at the time of randomization (p for interaction=0.01) but not TIA at the time of randomization (p for interaction=0.36). Conclusions: In the POINT trial, efficacy of DAPT was greater in patients with infarct on imaging attributed to the index event. Future work should focus on determining clinical factors associated with this group to help identify patients most likely to benefit from acute DAPT.

Cardiomyocyte Oga haploinsufficiency increases O-GlcNAcylation but hastens ventricular dysfunction following myocardial infarction.

RationaleThe beta-O-linkage of N-acetylglucosamine (i.e., O-GlcNAc) to proteins is a pro-adaptive response to cellular insults. To this end, increased protein O-GlcNAcylation improves short-term survival of cardiomyocytes subjected to acute injury. This observation has been repeated by multiple groups and in multiple models; however, whether increased protein O-GlcNAcylation plays a beneficial role in more chronic settings remains an open question.ObjectiveHere, we queried whether increasing levels of cardiac protein O-GlcNAcylation would be beneficial during infarct-induced heart failure.Methods and resultsTo achieve increased protein O-GlcNAcylation, we targeted Oga, the gene responsible for removing O-GlcNAc from proteins. Here, we generated mice with cardiomyocyte-restricted, tamoxifen-inducible haploinsufficient Oga gene. In the absence of infarction, we observed a slight reduction in ejection fraction in Oga deficient mice. Overall, Oga reduction had no major impact on ventricular function. In additional cohorts, mice of both sexes and both genotypes were subjected to infarct-induced heart failure and followed for up to four weeks, during which time cardiac function was assessed via echocardiography. Contrary to our prediction, the Oga deficient mice exhibited exacerbated—not improved—cardiac function at one week following infarction. When the observation was extended to 4 wk post-MI, this acute exacerbation was lost.ConclusionsThe present findings, coupled with our previous work, suggest that altering the ability of cardiomyocytes to either add or remove O-GlcNAc modifications to proteins exacerbates early infarct-induced heart failure. We speculate that more nuanced approaches to regulating O-GlcNAcylation are needed to understand its role—and, in particular, the possibility of cycling, in the pathophysiology of the failing heart.

P5158Microencapsulated insulin like growth factor 1 improves cardiac function after experimental infarction in absence of angiogenesis

P5158Microencapsulated insulin like growth factor 1 improves cardiac function after experimental infarction in absence of angiogenesis

Intra-arterial versus intravenous abciximab therapy for thromboembolic complications of neuroendovascular procedures: case review and meta-analysis

BackgroundAbciximab is used to treat thromboembolic complications of neuroendovascular procedures, but outcomes of treatment are not well defined.ObjectiveTo examine the angiographic and clinical outcomes based on route of abciximab administration...

Takotsubo syndrome: Advances in the understanding and management of an enigmatic stress cardiomyopathy.

Takotsubo cardiomyopathy is a syndrome mimicking an acute myocardial infarction in absence of obstructive epicardial coronary artery disease to explain the degree of the wall motion abnormalities. Typically more common in the elderly women, this condition is usually triggered by unexpected emotional or physical stress situations, and is associated with electrocardiogram abnormalities and slight elevation of cardiac biomarkers. The pathophysiological mechanism is not clear yet, but it is believed that a high circulating concentration of catecholamines causes an acute dysfunction of the coronary microcirculation and metabolism of cardiomyocytes, leading to a transient myocardial stunning. Typically, it presents with acute left ventricular systolic dysfunction that in most cases is completely resolved at short term. Recurrences are rare and it is thought that the long-term prognosis is good. We present here a review of the clinical features, pathophysiology and management of this enigmatic condition.

Predictors of a Favorable Outcome after Recanalization in Patients with Cerebral Major Vessel Occlusion

Although tissue plasminogen activator and endovascular treatment were reported to be useful for recanalization in patients with major vessel occlusion (MVO), the outcome in some patients with recanalization was unfavorable. We could detect prolongation of the ipsilateral posterior cerebral artery (PCA) to the ischemic side on magnetic resonance angiography in some patients (ipsilateral-PCA sign). We investigated the predictors including radiological findings for a favorable outcome after successful recanalization. We included 76 patients with MVO of the anterior circulation and documented recanalization by treatment. We divided our patients into 2 groups: group F (modified Rankin scale [mRS] score = 0-2) and group UF (mRS score = 3-6). We compared biomarkers between the groups. National Institutes of Health Stroke Scale (NIHSS) score before treatment in group F (8.5) was lower than that in group UF (16.0; P <.001). Sensitivity of the ipsilateral-PCA sign was commonly associated with group F (67.5% versus 19.4%, P <.001), and specificity of the sign was 80.6%. Absence of infarcts in the anterior cerebral artery (ACA) territory and ACA occlusion were also associated with a favorable outcome. In multivariate analysis, the ipsilateral-PCA sign and NIHSS score (≤ 10) were independent predictors of favorable outcome (odds ratio = 9.92, 95% confidence interval [CI] 2.71-36.23, P = .001; and odds ratio = 9.15, 95% CI 2.44-34.36, P = .001, respectively) The ipsilateral-PCA sign and low NIHSS score (≤ 10) were predictors of a favorable outcome in patients with MVO and documented recanalization by treatments.

Abstract T MP116: Coated-Platelets Predict Stroke at 30 days in Patients with Transient Ischemic Attack

Background: Coated-platelets, a subset of procoagulant platelets observed upon dual agonist stimulation with collagen and thrombin, support a robust prothrombinase activity and provide a unique measure of platelet thrombotic potential. Coated-platelet levels are increased both in non-lacunar stroke and transient ischemic attack (TIA) compared to controls free of stroke or TIA. In addition, higher levels in non-lacunar stroke are associated with stroke recurrence. We now examine whether coated-platelet levels predict stroke at 30 days in TIA patients. Methods: Consecutive patients with a diagnosis of TIA established by a board certified neurologist were enrolled in this pilot study. The diagnosis was consistent with the tissue-based definition of TIA: a transient episode of neurological dysfunction without acute infarction. The absence of infarction was demonstrated by normal brain imaging studies. Those taking anticoagulants or with dementia were excluded. Coated-platelets were determined at baseline and reported as percent of cells converted to coated-platelets. A receiver operating characteristic curve (ROC) analysis was conducted to compare the ability of coated-platelets versus chance alone to predict incident stroke at 30 days. Results: We enrolled 171 patients. Ten strokes were observed at 30 days. ROC analysis showed significant improvement in the predictive ability of the coated-platelets model compared to chance (AUC: 0.78 ± 0.07 versus 0.50 ± 0, respectively; p &lt; 0.0001). A cut-off of 51.1% for coated-platelet levels yielded a sensitivity of 0.80 (0.55-1.0; 95% CI), specificity of 0.73 (0.66-0.80), positive predictive value of 0.16 (0.06-0.26), and a negative predictive value of 0.98 (0.96-1.0). Conclusions: Among these subjects with TIA, coated platelet levels &lt;51.1% at time of presentation had a negative predictive value of 98% for stroke at 30 days. These findings suggest a role for coated-platelets in stroke risk stratification following TIA.

Revascularization of Chronic Hibernating Myocardium Stimulates Myocyte Proliferation and Partially Reverses Chronic Adaptations to Ischemia

BackgroundThe time course and extent of recovery after revascularization of viable dysfunctional myocardium are variable. Although fibrosis is a major determinant, myocyte structural and molecular remodeling may also play important roles. ObjectivesThis study sought to determine whether persistent myocyte loss and/or irreversibility of protein changes that develop in hibernating myocardium have an impact on functional recovery in the absence of infarction. MethodsSwine implanted with a chronic left anterior descending artery (LAD) stenosis to produce hibernating myocardium underwent percutaneous revascularization, with serial functional recovery evaluated for 1 month (n = 12). Myocardial tissue was evaluated to assess myocyte size, nuclear density, and proliferation indexes in comparison with those of normal animals and nonrevascularized controls. Proteomic analysis by 2-dimensional differential in-gel electrophoresis was used to determine the reversibility of molecular adaptations of hibernating myocytes. ResultsAt 3 months, physiological features of hibernating myocardium were confirmed, with depressed LAD wall thickening and no significant infarction. Revascularization normalized LAD flow reserve, with no immediate change in LAD wall thickening. Regional LAD wall thickening slowly improved but remained depressed 1 month post–percutaneous coronary intervention. Surprisingly, revascularization was associated with histological evidence of myocytes re-entering the growth phase of the cell cycle and increases in the number of c-Kit+ cells. Myocyte nuclear density returned to normal, whereas regional myocyte hypertrophy regressed. Proteomic analysis demonstrated heterogeneous effects of revascularization. Up-regulated stress and cytoskeletal proteins normalized, whereas reduced contractile and metabolic proteins persisted. ConclusionsDelayed recovery of hibernating myocardium in the absence of scar may reflect persistent reductions in the amounts of contractile and metabolic proteins. Although revascularization appeared to stimulate myocyte proliferation, the persistence of small immature myocytes may have contributed to delayed functional recovery.

Relationship of Microalbuminurea in Non-Diabetic and Non-Hypertensive Patients with Acute Myocardial Infarction

Background and objective: Microalbuminuria (MA) has implications on the development of CHD and it is emerging as a new risk factor of this disease. The aim of the present study was to assess the prevalence of microalbuminuria in non-diabetic and non-hypertensive subjects suffering from acute myocardial infarction, short term outcome and its prognostic importance as indicator of cardiovascular morbidity and mortality. To evaluate the relationship between Microalbuminuria and Acute Myocardial Infarction in Non-diabetic and non- hypertensive patients admitted in CCU Cardiology Department LUMHS Hyderabad. Material and methods: A cross-sectional and hospital based study. 126 consecutivenon diabetic non hypertensive patients of acute myocardial infarction were included in this study. Microalbuminuria was determined by immunoturbedimeteric method. Serum glucose and urea were measured by enzymatic method. Serum creatinine was measured by kinetic colorimetric method. Results: A significant Microalbuminuria was found in patients of AMI who were non diabetic and non-hypertensive. The mortality and morbidity in short term outcome was also significantly increased in patients having MA, indicating the significance of Microalbuminuria as powerful prognostic biomarker. Conclusion: Microalbuminuria may have an association with acute myocardial infarction in absence of traditional risk factors like Diabetes and Hypertension.

Silent Cerebral Infarcts and Cerebral Aneurysms Are Prevalent in Adults with Sickle Cell Disease

Introduction: Neurologic complications are a major cause of morbidity in sickle cell disease (SCD). The cumulative cerebral risk for neurological complications in sickle cell anemia has been estimated around 50% by age 14 (Bernaudin et. al, 2011;Blood 4:1130-40). Silent cerebral infarcts (SCI), is the most commonly recognized cause of neurological injury, associated with cognitive difficulties (King et al, Am J Hematol 2014;89:162-7) found in 20-40% of children with SCD, more common in genotype SS or Sβ0 thalassemia. The prevalence of SCI has not been well studied in adults. The prevalence of intracranial saccular aneurysms by radiographic and autopsy series is estimated to be 3.2% in a population without comorbidity, a mean age of 50 years, and a 1:1 gender ratio. (Valk et al, Lancet Neurol 2011; 10: 626–36) while other investigators found a 1.8% prevalence and no increased incidence with age (Vernooij et al NEJM 2007;357:1821-8). The goal of this study was to assess the prevalence of neurologic morbidity, including SCI, overt stroke, and cerebral aneurysm, in a large cohort of adults with SCD. We hypothesized the SCI would be more prevalent in adults compared to children with SCD.Methods: Due to the high prevalence of cerebral infarcts in children with SCD, we elected to obtain as part of routine clinical practice, a MRI and magnetic resonance angiography (MRA) of the brain in adultswith SCD in our Hematology clinic. As standard care if SCIs are seen, neurocognitive testing is recommended, and based on this testing and MRI results, appropriate patients are referred for vocational rehabilitation service. All MRIs and MRAs were reviewed by 2 board certified neuroradiologists and consensus findings were recorded including presence of cerebral infarcts, intracerebral hemorrhage, aneurysms and cerebralvasculopathy. All adults with SCD were followed by a single hematologist and were asked about neurological symptoms. Medical records were reviewed to see if stroke like symptoms had been reported. If no symptoms were reported and no abnormalities were documented on neurological examination, then infarcts were judged to be silent.Results: The study population included 94 adults with SCD (80% HbSS or Hb Sβ0 thalassemia; 11% HbSC, and 9% other), 51% males, median age 26 years, interquartile range (22-36 years) who had MRI of the brain and 88 had MRA of the brain. Of these, 91 MRIs were of sufficient quality to assess for the presence or absence of infarcts. Infarcts were present in 58% (53 individuals) with multiple infarcts in 40% (37 patients); infarcts were overt/symptomatic in 13% (12) and silent in 45% (41). Hemorrhages were present in 8 patients (9%) and of these, 7 of 8 also had infarcts present on MRI. MRI and MRA of the brain were felt of adequate quality to assess for vascular disease or aneurysm in 79 patients. Of these 7.5% (6 of 79 patients) had moyamoya vasculopathy and 7.5% (6 of 79 patients) had saccular aneurysms with no overlap between groups. All of the adults with moyamoya vasculopathy had overt strokes. The aneurysms were incidental findings and all were <5mm in size. Patients were referred to Neurosurgery for evaluation of aneurysmal lesions. Amongst the 12 adults with a history of overt stroke, 67% were on therapy (50% on hydroxyurea therapy; 17% on chronic blood transfusion therapy), 42% (5 of 12) received aspirin for stroke and 1 patient was already on warfarin for history of systemic thrombosis at the time of stroke.Conclusions: Silent cerebral infarctions are common in adults with SCD. Silent cerebral infarcts were present in 45% and over strokes had occurred in 13% of adults with SCD. Our aneurysm prevalence of 7.5% in a younger cohort (median age 26 years) suggests that adults with SCD may have a higher prevalence of cerebral aneurysms than the general population. Further study is warranted to assess whether SCD should be considered a comorbidity that confers a higher risk of cerebral aneurysm in adults. The optimal strategies for primary and secondary stroke prevention and to mitigate against the progressive cerebral vasculopathy in adults with SCD are still being debated. DisclosuresNo relevant conflicts of interest to declare.

Abstract 15526: Predictors of Elective Support Device Insertion Prior to High Risk Percutaneous Coronary Intervention: Changing Trends between 1993-2013

Introduction: High risk percutaneous coronary interventions (PCI) may be preceded by elective support device insertion, though the evidence for such a practice is relatively weak. We sought to analyze the changing trends and predictors for prophylactic support device insertion in these patients over the last 20 years. Methods: Retrospective analysis of all patients who underwent PCI at Cleveland Clinic between 1993 - 2013 with or without support device insertion was performed. Trends for device insertion in high risk patients undergoing PCI, like those in clinical shock, acute myocardial infarction (MI) and unprotected left main intervention over the last 20 years were reviewed. Predictors for support device insertion in these patients from 1993-2000 were compared to those from 2001-2013. Results: A total of 666 elective support devices were inserted prior to high risk PCI from 1993-2013. Between 1993-2000, acute myocardial infarction (MI) (OR: 10.05), ejection fraction &lt; 40% (OR: 8.31) and unprotected left main intervention (OR: 4.59) were the three most significant predictors for device insertion prophylactically. Between 2001-2013, unprotected left main intervention (OR: 9.91), ejection fraction &lt; 40% (OR: 5.61) and clinical shock (OR: 5.24) were the biggest predictors, with the odds of support device insertion in acute MI in absence of clinical shock reduced to 1.96. Conclusions: There has been a significant decrease in the proportion of high risk PCIs with elective support device insertion, especially in those performed in patients with acute myocardial infarction in absence of shock.

Persistent migraine aura: new cases, a literature review, and ideas about pathophysiology.

Persistent migraine aura without infarction (PMA) is a rare condition that is defined as an aura that lasts longer than 1 week in absence of infarction. Two types of PMA have been distinguished, notably persistent primary visual disturbance (PPVD) and typical aura (TA). This case-based review article describes four new cases of PMA as well as reviews all cases reported, trying to identify relevant associations, in particular with respect to functional investigations. We performed a systematic literature search, extending from the period when it was first described (1991) to March 2014. We included all case descriptions of which criteria for PMA formulated in the International Classification of Headache Disorders, second edition, were met. In addition, we described four new cases. We identified 47 cases of PMA, 27 PMA-PPVD and 19 PMA-TA. In one case, there was not enough information to define the type of PMA. The mean age of onset was 30 years, varying from 7 to 74 years. The duration of symptoms varied from 9 days to 28 years. Besides a longer duration in symptoms in the PMA-PPVD group, we could not identify any differences between these groups. Some authors report occipital hypoactivity on Tc99m-hexamethylpropylene amine oxime -single-photon emission computed tomography (Tc99m-HMPAO-SPECT) or fluorodeoxyglucose-positron emission tomography (FDG-PET) in PMA cases, but data are inconsistent. Multiple drugs have been used for the treatment of PMA, usually with little effect. Lamotrigine seems to be the most effective drug. Despite the fact that 47 cases of PMA have been reviewed in this paper, many questions remain. The cases that have been described so far show inconsistent data with respect to the results of functional studies as well as treatment effects. The pathophysiology of PMA is still largely a matter of conjecture.

Posterior reversible encephalopathy syndrome (PRES) in an HIV-1 infected patient with disseminated varicella zoster virus: a case report

BackgroundPosterior reversible encephalopathy syndrome (PRES) is an uncommon pathology characterized by the acute onset of headache, vomiting, altered consciousness, seizures and focal neurological deficits. It was initially described in the setting of hypertension, uremia and immunosuppression. In the last decade there have been emerging reports of PRES in patients with advanced human immunodeficiency virus (HIV)-infection in the presence of hypertension, dialysis, hypercalcaemia and two opportunistic infections: blastomycosis and tuberculosis (TB).Case presentationHere we present the case of a 54 year old male being treated for disseminated varicella zoster virus (VZV) and vasculopathy in the setting of HIV infection who acutely deteriorated to the point of requiring intubation. His clinicoradiological diagnosis was of PRES and he subsequently improved within 72 h with supportive management. Serial neuroimaging correlated with the clinical findings. The pathogenesis of PRES is poorly understood but is thought to stem from vasogenic oedema either as a result of loss of endothelial integrity and transudate of fluid across the blood–brain barrier, or secondary to vasospasm resulting in tissue oedema in the absence of infarction. How HIV infection impacts on this model is unclear. It is possible the HIV infection causes endothelial dysfunction and disruption of the blood–brain barrier that may be further exacerbated by infections in the central nervous system.ConclusionThe phenomenon of PRES in advanced HIV is an important clinical entity for both physicians and critical care doctors to recognize firstly given its potential mortality but also because of its favourable prognosis and reversibility with supportive care and treatment of underlying causes.