Acute Cerebrovascular Events Research Articles

Incidence of acute cerebrovascular events in patients with rheumatic or calcific mitral stenosis: A systematic review and meta-analysis.

Patients with mitral stenosis (MS) may be predisposed to acute cerebrovascular events (ACE) and peripheral thromboembolic events (TEE). Concomitant atrial fibrillation (AF), mitral annular calcification (MAC) and rheumatic heart disease (RHD) are independent risk factors. Our aim was to evaluate the incidence of ACEs in MS patients and the implications of AF, MAC and RHD on thromboembolic risks. This systematic review was registered on PROSPERO (CRD42021291316). Six databases were searched from inception to 19th December 2021. The clinical outcomes were composite ACE, ischaemic stroke/transient ischaemic attack (TIA) and peripheral TEE. We included 16 and 9 papers, respectively, in our qualitative and quantitative analyses. The MS cohort with AF had the highest incidence of composite ACE (31.55%; 95% CI 3.60-85.03; I2=99%), followed by the MAC (14.85%; 95% CI 7.21-28.11; I2=98%), overall MS (8.30%; 95% CI 3.45-18.63; I2=96%) and rheumatic MS population (4.92%; 95% CI 3.53-6.83; I2=38%). Stroke/TIA were reported in 29.62% of the concomitant AF subgroup (95% CI 2.91-85.51; I2=99%) and in 7.11% of the overall MS patients (95% CI 1.91-23.16; I2=97%). However, the heterogeneity of the pooled incidence of clinical outcomes in all groups, except the rheumatic MS group, was substantial and significant. The logit-transformed proportion of composite ACE increased by 0.0141 (95% CI 0.0111-0.0171; p<0.01) per year of follow-up. In the MS population, MAC and concomitant AF are risk factors for the development of ACE. The scarcity of data in our systematic review reflects the need for further studies to explore thromboembolic risks in all MS subtypes.

Propensity score-matched study of uni-condylar arthroplasty in elderly patients with knee osteoarthritis

To investigate the clinical efficacy of unicompartmental knee arthroplasty (UKA) in the treatment of knee osteoarthritis in patients over 75 years old. The clinical efficacy of primary fixed platform UKA in patients with osteoarthritis, was retrospectively analyzed from October 2014 to November 2020. Age, body mass index (BMI), range of motion (ROM), preoperative joint function score, the quality of life score and other preoperative indicators were measured by propensity score matching (PSM). The patients were divided into elderly group (≥75 years old) and control group (<75 years old). Oxford knee score(OKS), Western Ontario McMaster Universities osteoarthritis index(WOMAC), Short Form-12 including physical component summary (PCS), mental component summary(MCS), minimal clinically important difference(MCID ) and clinical complications were evaluated preoperatively and postoperatively. A total of 514 patients were analyzed, 428 patients fulfilled the inclusion criteria. A propensity-score matching study was conducted to eliminate confounding factors. After 1∶2 propensity match, there were 84 patients in elderly group (≥75 years), age ranged from 75 to 88 years old, with an average of (78.79±3.08) years old, and 168 patients in control group (<75 years), age ranged from 47 to 74 years old, with an average of (64.10±5.96)years old. The follow-up duration of two groups ranged from 12 to 84 months with an average of (29.35±16.52) months in elderly group, and 12 to 85 months with an average of (31.83±17.34) months in control group. There was only significant difference in age between the elderly and control groups preoperatively (P<0.01). Postoperatively, the elderly group showed significantly higher WOMAC (P<0.01) and lower SF-12 PCS scores (P<0.01) as compared to the control group. There was no significant difference between the elderly group and the control group in knee range of motion, OKS and the proportion of each scoring system reaching the minimum clinical difference value (P>0.05). In the aspect of preperative complications, the elderly group exhibited more surgical site complications and postoperative delirium compared to control group(P<0.05). The differences in other indicators including deep vein thrombosis, acute urinary retention, cardiovascular events, cerebrovascular events and radiolucent lines around prothesis were not statistically significant(P>0.05). UKA in the treatment of elderly patients over 75 years old with knee osteoarthritis was safe and feasible, and could obtain satisfactory short-term efficacy.

Computed Tomography Perfusion Imaging in Acute Ischemic Stroke: Accurate Interpretation Matters.

Computed Tomography Perfusion Imaging in Acute Ischemic Stroke: Accurate Interpretation Matters.

Atherosclerotic carotid plaque characteristics vary with time from ischemic event: A multicenter, prospective magnetic resonance vessel wall imaging registry study

Recent studies report that the rate of recurrent stroke is highest in the stages immediately following cerebral infarction and decreases over time in patients with atherosclerotic carotid stenosis. The purpose of this study was to identify temporal differences in early stage carotid plaque components from acute cerebrovascular ischemic events using carotid MRI. Carotid plaque images were obtained on 3 T MRI from 128 patients enrolled in MR-CAS. Among the 128 subjects, 53 were symptomatic and 75 asymptomatic. The symptomatic patients were classified into three groups based on interval from onset of symptoms to the date of the carotid MRI (Group <14 days; 15-30 days; and > 30 days). The volume of each plaque component was identified and quantified from MR images. The presence of juxtaluminal loose matrix/inflammation (LM/I) was identified as a possible indicator of inflammation on the luminal side. Plaque components were compared between groups using the Wilcoxon rank-sum or the Chi-square test. Patient characteristics and carotid plaque morphology were similar among all four groups. The median volume of LM/I in Group >30 days was significantly lower than in other groups (0 mm3 vs 12.3 mm3 and 18.1 mm3; p = 0.003). In addition, the prevalence of juxtaluminal LM/I decreased over time (ptrend = 0.002). There were no statistically significant differences in other plaque components between the symptomatic groups. The volume of LM/I was significantly smaller in Group >30 days and prevalence of juxtaluminal LM/I in the atherosclerotic carotid plaque was high in the early stages after events. This suggests that carotid plaques undergo rapid evolution after an acute cerebrovascular ischemic event.

Abstract TP167: Burden And Impact Of Comorbid Depression On In-hospital Outcomes Of Acute Ischemic Stroke-related Admissions In Women Of Reproductive Age Group: A Propensity-matched Analysis

Background: Depression has been identified as a risk factor for acute cerebrovascular events. Due to limited data focused on young females, we studied the burden and impact of comorbid depression on outcomes of acute ischemic stroke (AIS)-related admissions in young women of the reproductive age group. Methods: We used the National Inpatient Sample (2018) to identify admissions of young females (age 18-44 years) with AIS; and further classified it into two demographically (age, race, payer status, income) matched (1:1) groups based on the presence of comorbid depression. Comorbidities and outcomes were compared using relevant ICD-10 codes. Multivariable regression was used to analyze the association of comorbid depression with in-hospital mortality. Results: In 15850 young females admitted with AIS in 2018, 2465 (15.6%) had comorbid depression. Post-matching, the study cohort consisted of 4610 women admitted with AIS (Median age: 37, 66.2% whites) and 2305 women in each cohort, with and without depression. The matched AIS-depression arm often had younger women (median 37 vs 39 years), patients from the lower-income quartile (47.3% vs. 34.5%), and higher rates of obesity, peripheral vascular disease, and prior history of stroke but a lower prevalence of CVD risk factors [Table 1]. The depression arm had a non-significant odd of all-cause mortality (OR 1.32, 95%CI:0.64-2.74) when adjusted for sociodemographic confounders and comorbid risk factors (p=0.452). The LOS was shorter (median 4 vs 5 days) with comparable hospital charges in the depression arm vs. no depression arm (p&lt;0.001). Conclusion: This study revealed a nearly 15% burden of depression in young females admitted for AIS without significant impact on all-cause mortality when controlled for confounders. The impact of depression on long-term AIS outcomes needs further evaluation.

Major adverse cardiovascular events among patients with type-2 diabetes, a nationwide cohort study comparing primary metabolic and bariatric surgery to GLP-1 receptor agonist treatment

BackgroundGlucagon-like Peptide-1 receptor agonists (GLP-1 RA) and metabolic and bariatric surgery (MBS) both improve cardiovascular outcomes in patients with severe obesity and type-2 diabetes (T2D). The aim of the present study was to assess the impact of MBS on major cardiovascular adverse events (MACE) in patients with severe obesity and T2D compared to patients with T2D treated with GLP-1 RA.Subjects and methodsIn this propensity score matched cohort study on nationwide data, patients with T2D and severe obesity who underwent MBS in Sweden from 2007 until 2019 were identified from the Scandinavian Obesity Surgery Registry and matched to a non-surgical group with T2D treated with GLP-1 RA (81.7% liraglutide, 9.0% dulaglutide, 6.0% exenatide, 1.6% lixisenatide and 0.8% semaglutide) from the general population using generalized linear model. Major outcome was MACE (hospitalization for acute coronary syndrome or cerebrovascular event or all-cause death), evaluated with multivariable Cox regression.ResultsIn total 2161 patients (obesity class I (10.2%), class II (40.3%), class III (49.5%)) were matched to 2161 non-surgical patients (mean age 51.1 ± 9.29 vs 51.5 ± 8.92 years, 64.8% vs. 64.4% women, with mean number of diabetes drugs of 2.5 ± 0.89 vs 2.6 ± 0.87, a mean duration of diabetes of 6.0 ± 4.15 vs 6.0 ± 4.51 years with 44.2% vs. 42.8% being treated with insulin at baseline). During the study period, 113 patients (8-year cumulative incidence 9.3%) compared to 130 non-surgical patients (8-year cumulative incidence 11.3%) suffered from MACE or all-cause mortality (HR 0.76, 95%CI 0.59–0.98), and 69 patients (8-year cumulative incidence 5.1%) compared to 92 non-surgical patients (8-year cumulative incidence 7.6%) suffered from a non-fatal MACE (HR 0.68, 95%CI 0.49–0.93).ConclusionIn this matched cohort study, MBS was associated with lower risk for MACE compared to treatment with early GLP-1 RA in patients with T2D.

Ticagrelor Aspirin vs Clopidogrel Aspirin in CYP2C19 Loss-of-Function Carriers With Minor Stroke or TIA Stratified by Risk Profile.

Genotype data of the Clopidogrel with Aspirin in Acute Minor Stroke or Transient Ischemic Attack (CHANCE) trial showed that efficacy of clopidogrel aspirin depended on CYP2C19 genotype and risk profile. A stratification of patients who carried CYP2C19 loss-of-function (LOF) alleles according to the risk of recurrent stroke may be important for selecting optimal antiplatelet therapy. We aimed to compare the efficacy and safety of ticagrelor aspirin with clopidogrel aspirin in CYP2C19 LOF carriers with minor stroke or transient ischemic attack (TIA) stratified by risk profile. Data were obtained from Ticagrelor or Clopidogrel with Aspirin in High-Risk Patients with Acute Nondisabling Cerebrovascular Events II (CHANCE-2) trial. Low-risk and high-risk profiles were defined by Essen Stroke Risk Score (ESRS) (<3 [low risk] and ≥3 [high risk], respectively). A total of 6,412 CYP2C19 LOF carriers were enrolled; ticagrelor aspirin was associated with a reduced risk of primary outcome (new stroke within 90-day follow-up) in patients at low risk (hazard ratio [HR], 0.65; 95% CI, 0.48-0.82), but not in those at high risk (HR, 0.97; 95% CI, 0.73-1.29), compared with clopidogrel aspirin (p = 0.02 for interaction). Secondary outcomes generally went in the same direction as the primary outcome. The primary safety outcome of severe or moderate bleeding did not differ based on risk profile (p = 0.24 for interaction), although the incidence of total bleeding was greater with ticagrelor aspirin than with clopidogrel aspirin among patients at low risk (p < 0.01 for interaction). Analysis in the per-protocol population yielded similar results. This post hoc analysis of CHANCE-2 trial showed that CYP2C19 LOF carriers with minor stroke or TIA at low risk of recurrent stroke received a greater benefit from ticagrelor aspirin than from clopidogrel aspirin. This study provides Class II evidence that CYP2C19 LOF carriers with minor stroke or TIA at low risk, but not at high risk, of recurrent stroke (by the ESRS) received a greater benefit from ticagrelor aspirin than from clopidogrel aspirin. URL: www. gov. Unique identifier: NCT04078737.

Thromboembolic Events in Patients with Influenza: A Scoping Review.

Influenza is an acute respiratory infection that usually causes a short-term and self-limiting illness. However, in high-risk populations, this can lead to several complications, with an increase in mortality. Aside from the well-known extrapulmonary complications, several studies have investigated the relationship between influenza and acute cardio and cerebrovascular events. Reviews of the thromboembolic complications associated with influenza are lacking. the study aims to conduct a scoping review to analyze the epidemiological and clinical characteristics of patients suffering from influenza and thromboembolic complications. A computerized search of historical published cases using PubMed and the terms "influenza" or "flu" and "thrombosis", "embolism", "thromboembolism", "stroke", or "infarct" for the last twenty-five years was conducted. Only articles reporting detailed data on patients with thromboembolic complications of laboratory-confirmed influenza were considered eligible for inclusion in the scoping review. Fifty-eight cases with laboratory documented influenza A or B and a related intravascular thrombosis were retrieved. Their characteristics were analyzed along with those of a patient who motivated our search. The localizations of thromboembolic events were pulmonary embolism 21/58 (36.2%), DVT 12/58 (20.6%), DVT and pulmonary embolism 3/58 (5.1%), acute ischemic stroke 11/58 (18.9%), arterial thrombosis 4/58 (6.8%), and acute myocardial infarction 5/58 (8.6%). Our findings are important in clarifying which thromboembolic complications are more frequent in adults and children with influenza. Symptoms of pulmonary embolism and influenza can be very similar, so a careful clinical evaluation is required for proper patient management, possible instrumental deepening, and appropriate pharmacological interventions, especially for patients with respiratory failure.

Aminotransferase Level and the Effects of Dual Antiplatelet in Minor Stroke or Transient Ischemic Attack: A post hoc Analysis of a Randomized Control Trial

Introduction: This study was intended to evaluate whether the safety and efficacy of dual antiplatelet treatment in patients with minor ischemic stroke (MIS) or transient ischemic attack (TIA) could be modified by the aminotransferase level. Also, we sought to assess the interaction between aminotransferase level and CYP2C19 loss-of-function status on the efficacy of dual antiplatelet therapy. Methods: This study is a post hoc analysis of the Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events (CHANCE) study, a double-blinded randomized control trial. We included 5,133 patients with a complete workup of baseline alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels. The primary outcome is stroke or TIA recurrence within 90 days. Cox proportional hazard models were used in the evaluation of the efficacy of antiplatelet treatment in patients with different aminotransferase levels and subgroups categorized by the aminotransferase level × CYP2C19 loss-of-function status. Results: The median age of all the included patients was 62 years; 66.3% of the patients were male. More recurrent stroke or TIA occurred in patients with elevated ALT and AST levels within 90 days compared to patients with normal ALT and AST levels (14.5 vs. 11.2%, p = 0.029). Dual antiplatelet treatment with aspirin and clopidogrel reduced recurrence compared with aspirin alone in patients with both normal (adjusted hazard ratio [HR], 95% confidence interval [CI]: 0.72 [0.60–0.86], p < 0.001) and elevated (adjusted HR [95% CI]: 0. 57 [0. 35–0. 92], p = 0. 020) ALT and AST levels (p = 0.64 for interaction). No significant difference in treatment efficacy on 90-day all-cause death or bleeding events was found. Conclusions: Dual antiplatelet treatment was safe for minor stroke or high-risk TIA patients with mildly elevated aminotransferase. Mild elevation of ALT or AST did not undermine the protective efficacy of the dual antiplatelet regimen in reducing recurrent stroke or TIA within 90 days after MIS or TIA. The interaction between the CYP2C19 loss-of-function allele carrier status and aminotransferase level on the efficacy of dual antiplatelet treatment was not observed.

Neuregulin-1 attenuates hemolysis- and ischemia induced-cerebrovascular inflammation associated with sickle cell disease

ObjectivesIndividuals with sickle cell disease (SCD) are at severely heightened risk for cerebrovascular injury and acute cerebrovascular events, including ischemic and hemorrhagic stroke, potentially leading to impaired development and life-long physical and cognitive disabilities. Cerebrovascular injury specific to SCD includes inflammation caused by underlying conditions of chronic hemolysis and reduced cerebrovascular perfusion. The objectives of this study were to investigate whether expression of neuregulin-1β (NRG-1), an endogenous neuroprotective polypeptide, is increased in SCD or experimental conditions mimicking the hemolysis and ischemic conditions of SCD, and to determine if treatment with exogenous NRG-1 reduces markers of cerebrovascular inflammation. Materials and methodsPlasma and brain-specific NRG-1 levels were measured in transgenic SCD mice. Endogenous NRG-1 levels and response to experimental conditions of excess heme and ischemia were measured in cultured human brain microvascular cells and astrocytes. Pre-treatment with NRG-1 was used to determine NRG-1’s ability to ameliorate resultant cerebrovascular inflammation. ResultsPlasma and brain-specific NRG-1 were elevated in transgenic SCD mice compared to healthy controls. Neuregulin-1 expression was significantly increased in cultured human microvascular cells and astrocytes exposed to excess heme and ischemia. Pre-treatment with NRG-1 reduced inflammatory chemokine (CXCL-1 and CXCL-10) and adhesion molecule (ICAM-1 and VCAM-1) expression and increased pro-angiogenic factors (VEGF-A) in microvascular cells and astrocytes exposed to excess heme and ischemia. ConclusionsElevated NRG-1 in SCD is likely a protective endogenous response to ongoing cerebrovascular insults caused by chronic hemolysis and reduced cerebrovascular perfusion. Administration of NRG-1 to reduce cerebrovascular inflammation may be therapeutically beneficial in SCD and warrants continued investigation.

Prevalence of neurological complaints among emergency department patients with severe hypertension

ObjectiveSevere hypertension can accompany neurological symptoms without obvious signs of target organ damage. However, acute cerebrovascular events can also be a cause and consequence of severe hypertension. We therefore use US population-level data to determine prevalence and clinical characteristics of patients with severe hypertension and neurological complaints. MethodsWe used nationally representative data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) collected in 2016–2019 to identify adult ED patients with severely elevated blood pressure (BP) defined as systolic BP ≥ 180 mmHg and/or diastolic BP ≥120 mmHg. We used ED reason for visit data fields to define neurological complaints and used diagnosis data fields to define acute target organ damage. We applied survey visit weights to obtain national estimates. ResultsBased on 5083 observations, an estimated 40.4 million patients (95% CI: 37.5–43.0 million) in EDs nationwide from 2016 to 2019 had severe hypertension, equating to 6.1% (95% CI: 5.7–6.5%) of all ED visits. Only 2.8% (95% CI: 2.0–3.9%) of ED patients with severe hypertension were diagnosed with acute cerebrovascular disease; hypertensive urgency was diagnosed in 92.0% (95% CI: 90.3–93.4%). Neurological complaints were frequent in both patients with (75.6%) and without (19.9%) cerebrovascular diagnoses. Hypertensive urgency patients with neurological complaints were more often older, female, had prior stroke/TIA, and had neuroimaging than patients without these complaints. Non-migraine headache and vertigo were the most common neurological complaints recorded. ConclusionIn a nationally representative survey, one-in-sixteen ED patients had severely elevated BP and one-fifth of those patients had neurological complaints.

Acute Venous and Arterial Thromboembolic Events in Patients with Monoclonal Gammopathy of Undetermined Significance: A Nation Wide Analysis

Introduction: Monoclonal Gammopathy of Undetermined Significance (MGUS) is a premalignant plasma cell disorder. It is found in over 3% of patients who are 50 years of age or older (Kyle et al., 2006). MGUS is usually asymptomatic; however, it carries an increased risk of certain comorbidities. Some literature suggests an increased risk of venous and arterial thromboembolism in MGUS patients. We sought to examine this relationship using data from the National Inpatient Sample (NIS). Methods: We conducted a cross-sectional study using data from the NIS from the year 2016. We evaluated the frequencies of composite venous and composite arterial thromboembolism outcomes in adult patients with MGUS compared with those who had no history of the disease. IBM SPSS 26.0 was used for analysis. We constructed several logistic regression models to adjust for common confounding variables, including age, sex, race, and expected primary payer. Adjusted odds ratios and confidence intervals were calculated for each composite and component variable. Chi-square tests were used for comparing categorical variables. Results: We identified a total of 8500 patients with the diagnosis of MGUS. Among patients with MGUS, 135 patients (1.6%) had the primary diagnosis of a venous thromboembolic event. These included 55 patients (0.65%) who had acute deep vein thromboembolic events and 80 patients (0.94%) who had pulmonary embolism. Also, 374 patients (4.4%) had the primary diagnosis of an arterial thromboembolic event. These arterial events were divided into 3 categories as follows: 171 discharges (2.01%) were acute thrombo-embolic cardiac events, 190 discharges (2.24%) were acute cerebrovascular ischemic events, and 13 discharges (0.15%) with other arterial thromboembolic events. Patients with MGUS had an increased risk of the composite venous thromboembolism outcome (adjusted odds ratio [OR] 1.271, 95% CI 1.069-1.512). Analysis of the individual components showed a significant increase in the risk of acute deep vein thrombosis (adjusted OR 1.366, 95% CI 1.047-1.782) but failed to show a significant association with the risk of pulmonary embolism (adjusted OR 1.207, 95% CI 0.962-1.513). On the other hand, we found a reduced risk of composite arterial thromboembolism outcome in patients with MGUS (adjusted OR 0.617, 95% CI 0.555-0.685). Individual components analysis showed a reduction in the risk of acute thromboembolic cardiac events (adjusted OR 0.636, 95% CI 0.546-741) and acute ischemic cerebrovascular events (adjusted OR 0.595, 95% CI 0.514-689), but no significant difference was noted in the third group which included other arterial thromboembolic events (adjusted OR 1.343, 95% CI 0.779-2.317). Conclusion: Patients with MGUS had increased odds of developing acute venous thromboembolism, especially deep vein thrombosis, when compared to patients who had no history of MGUS. Interestingly, MGUS patients had reduced odds of developing acute cardiac and cerebrovascular arterial thromboembolic events. More research is required to assess the optimal approach for venous thromboembolism prophylaxis in MGUS patients.

Ixazomib, Lenalidomide, and Dexamethasone (IRd) Versus Ixazomib, Pegylated Liposomal Adriamycin, and Dexamethasone(IDd) in Elderly Frail Newly Diagnosed Multiple Myeloma with GA Score ≥2: A Prospective Multicenter Study

Introduction Frailty patients with newly diagnosed multiple myeloma (NDMM) have inferior survival and higher rate of treatment discontinuation due to complications, poor tolerance and compliance and lack of effective treatment. The aim of this study was to prospectively investigate the treatment tolerability, clinical outcomes and quality of life of the ixazomib based regimens in frail NDMM patients according to IMWG frailty index. This trail is registered at http://www.chictr.org.cn/index.aspx as chiCTR1900024917. Methods This prospective trail was an investigator initiate, multicenter, non-randomized controlled study which frail NDMM patients received 6-8 four-week induction cycles of ixazomib, lenalidomide and dexamethasone (IRd) and ixazomib, pegylated liposome adriamycin and dexamethasone (IDd), followed by matienance therapy of 4-week with ixazomib and dexamethasone (Id) until progression. Inclusion criteria were aged ≥ 65 years, IMWG GA score ≥ 2 or Mayo geriatric vulnerability scoring system defined as vulnerable. Main exclusion criteria were acute cardiovascular and cerebrovascular events. The primary endpoint was overall response rate (ORR) defined by having at least a partial response (≥PR). The secondary endpoints were progression free survival (PFS), overall survival (OS), adverse events (AE) and health-related quality of life (using the EORTC-QLQ C30). Results From July 2019 to December 2021, a total of 132 patients from 15 hospitals were enrolled of which 12 were excluded because of ineligibility and non-randomized assigned to receive IRd group (n=60) or IDd (n=60) according to doctor's estimated (Figure 1). The median age was 71 years range (65-88). All patients had a GA Index higher than 2 score, in which 27.5% were also defined fragile by Mayo criterion. The ORR was 83%, including 22 (19.6%) patients with a complete response (CR) and 45 (40.2%) with a very good partial response (VGPR). The ORR was 84.2% and 81.8%, CR was 26.3% and 17.2, VGPR was 36.8% and 43.6% of IRd and IAd group, respectively. After a median follow-up time of 22.9m (95% CI 18.9-26.9), the median PFS was 19.5m of all patients, 24.6m and 15.8 of IRd and IDd group, respectively. The median OS of all patients and IRd group was no reach, while 29.2m in IDd group (Figure 1). Four patients died in 60 days post enroll up because of pneumonia caused by bedridden. Twenty-six and thirty-six patients did not process to maintenance therapy in IRd and IAd group, due to PD (14 in IRd and 16 in IDd), AE (6 in IRd and 7 in IDd), incompliance (5 in IRd and 9 in IDd) and early death (1 in IRd and 3 in IDd). Cumulative grade 3 or higher hematological AEs occurred in 10/60 (16.7%) and 13/60 (21.7%), whereas grade ≥3 non-hematological AEs were reported in 25/60 (41.7%) and 46/60 (76.6%) patients. Most common non-hematological grade ≥3 AEs were infections (20.8%) and gastro-intestinal (13.3%). Only 1 patient experiencing PNP grade 3 (0.83%). During induction, patients experienced a statistically and clinically significant improvement in GHS/QoL of both IRd and IAd group (p<0.0001). (Figure 1) Conclusion The results of ORR and safety support the use of IDd or IRd as frontline therapy for fragile elderly MM patients, which also improves QoL. IDd was especially suitable for frail MM patients with renal dysfunction and thrombosis. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Quiescent Bilateral Internal Carotid Artery Dissection Following Strangulation

Bilateral internal carotid artery dissection is uncommon and suicide attempts by hanging represent a potential mechanism of direct vascular trauma. Previous reports have documented similar events and awareness is important as internal carotid artery dissection is an extensively recognized cause of acute cerebrovascular events. Our case is of a patient presenting with symptoms suggestive of an acute stroke. Significantly, there was a past medical history of an attempted suicide by hanging 4 years before this admission. Imaging demonstrated bilateral internal carotid artery dissection, an acute ischemic infarct and an incidental well-established infarct. Further investigations to assess an underlying aetiology of the bilateral internal carotid artery dissection were unsuccessful in identifying a secondary cause. Acute intracranial episodes related to traumatic internal carotid artery dissection following suicide attempts by hanging have previously been documented. However, such reports have frequently been temporally related to the period of trauma with patients developing neurological symptoms within a short timeframe after the hanging attempt. We hypothesize a delayed manifestation of underlying vascular damage caused by the inciting neck trauma by prior hanging attempt. The potential for internal carotid artery dissection and vascular distortion secondary to attempted hanging are suggestive of a high-risk cohort, and consideration of selective vascular imaging investigations of this group may be useful in acute stroke prevention.

Abstract 13524: Rising Burden of Acute Cardiovascular and Cerebrovascular Events in Young Females (18-44 Years) With Cannabis Use Disorder

Background: With the increasing recreational use of Cannabis in the United States, there is limited data on the impact of Cannabis use on young females. Therefore, we aimed to assess the risk and outcomes of cardiovascular and cerebrovascular events in young females with Cannabis use disorder (CUD). Method: The National Inpatient Sample (2019) was assessed to identify young, female hospitalizations (age 18-44 years) with CUD using relevant ICD-10 codes. Baseline characteristics and comorbidities were compared between two cohorts, CUD + and CUD -. The primary outcome was acute cardiovascular and cerebrovascular events evaluated using a multivariable regression analysis adjusting for confounders. Result: Of 1,72,36,228 young female hospitalizations, 2% had CUD+ (n=340560). CUD+ arm consisted of younger (median age-34 vs 59), black patients (28.2vs15.5%) and had a higher rate of drug abuse (62.1% vs 3%), smoking (50.7% vs 12.4%) and alcohol abuse (13.9% vs 2.5%) when compared to CUD- cohort (p&lt;0.001). Despite a lower prevalence of comorbidities (p&lt;0.001) such as Hypertension, Diabetes, Hyperlipidaemia, Obesity, PVD, CKD, Prior MI, Prior PCI, Prior CABG, Prior Stroke, Prior VTE, CUD+ group showed higher odds of Type 1 MI (OR=1.11,95%CI-1.04-1.18,p=0.001), Dysrhythmia (OR=1.08,95%CI-1.05-1.11,p-&lt;0.001), however the CUD+ cohort had lower odds of Type 2 MI(OR=0.89,95%CI-0.83-0.96,p-0.003), Cardiogenic Shock (OR=0.78,95%CI-0.7-0.87,p&lt;0.001), Cardiac arrest including VF (OR=0.79,95%CI-0.72-0.87,p&lt;0.001), and Acute PE (OR=0.74,95%CI-0.68-0.8,p&lt;0.001) as compared to without CUD cohort. Conclusion: Despite having an overall lower CVD risk burden, the CUD+ female cohort had a higher risk of Type 1 MI and Dysrhythmia after controlling for other confounding risk factors and substance abuse. abuse.

Electrocardiographic changes in patients with raised intracranial pressure from supratentorial brain tumors.

A wide variety of electrocardiographic (ECG) changes has been described in the context of neurological catastrophe. There has been diverse and plentiful literature emphasizing the cardiac changes in acute cerebrovascular events and traumatic brain injury. In stark contrast, there is scarce literature on the incidence of cardiac dysfunction caused by raised intracranial pressure (ICP) resulting from brain tumors. The study aimed to observe the ECG changes concurrent with intracranial hypertension resulting from supratentorial brain tumors. This is a pre-specified subgroup analysis of a prospective and observational study on cardiac function in patients presenting for neurosurgery. Data of 100 consecutive patients of either sex between 18 and 60 years who presented with primary supratentorial brain tumors were analyzed. The patients were divided into two groups: Group 1 consisted of patients without clinical and radiological features of raised ICP and Group 2 consisted of patients with clinical and radiological features of raised ICP. A 12-lead ECG was obtained for every patient on the day before the neurosurgical procedure as part of the pre-anesthetic assessment. The cardiologist and the neuroanesthetist independently examined the ECG, and it was then classified and coded as per the standardized Minnesota code. Statistical analysis was performed with IBM SPSS (release 22.0; IBM Corp., Armonk, NY, USA). The normality of the distribution of continuous variables was tested using the Shapiro-Wilk test. Normally distributed variables were expressed as Mean ± SD. All nominal or categorical variables are described as frequencies and percentages. Categorical variables were compared using the Chi-square test or the Fisher's exact test. The normally distributed continuous variables were compared using Student's t-test. "P < 0.05" was considered statistically significant. About 6% in Group 1 and 32% in Group 2 had abnormal ECG. This was significantly different in Group 2 compared to Group 1 (P < 0.05). No patients in Group 1 had sinus bradycardia, whereas it was observed in 12% of the patients in Group 2 (P = 0.02). ST-segment depression was found in 12% of patients in Group 2, whereas none had it in Group 1 (P = 0.02). ST-segment elevation was noticed in 16 % in Group 2 and 2% in Group 1 (P = 0.01). T-wave abnormalities were found in 16% compared to 4% in Group 1 (P = 0.03). In patients with supratentorial tumors, we observed that those with raised ICP had a higher incidence of ECG changes than those with normal ICP. In addition, repolarization abnormalities and arrhythmias were significantly higher in patients with raised ICP.

No rebound effect after a course of clopidogrel in patients with acute TIA or minor stroke

ABSTRACT Background and Purpose Previous studies demonstrated that discontinuation of clopidogrel in patients after ACS was associated with a rebound increase in risk of recurrent events. In this study, we aimed to investigate the rebound effect after discontinuation of clopidogrel therapy in patients with TIA or stroke. Methods All patients with minor stroke or TIA were recruited from the Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events (CHANCE) trial. Patients were divided into two groups: patients who discontinued clopidogrel and switched to aspirin therapy (Clopidogrel Discontinuation Group) and patients who continued one mono-antiplatelet therapy (non-Clopidogrel Discontinuation Group) during 90-180 days. The outcomes included risks of recurrent ischemic stroke, recurrent TIA, and composite events during 90-180 days. The prevalence of each outcome was compared between two groups for every 30 days. Further subgroup analysis was conducted in patients with and without CYP2C19 loss-of-function alleles. Results Among the 3456 patients included, a total of 10 patients in the Clopidogrel Discontinuation Group and 11 patients in the non-Clopidogrel Discontinuation Group presented ischemic stroke recurrence during the 90–180-day period. The inter-group comparisons were not significant in each 30 days. Similar results were found for recurrent stroke, recurrent TIA, and composite events in these two groups, which were also found in CYP2C19 subgroup analysis. Conclusions No rebound increase in the risk of ischemic stroke and composite events was found during the 90 days after discontinuation of clopidogrel therapy in patients with TIA or minor stroke in the CHANCE trial. Trial Registration clinicaltrials.gov Identifier: NCT00979589

Joint High Level of Oxidized Low-Density Lipoprotein and High-Sensitivity C-Reactive Protein are Associated With Recurrent Stroke and Poor Functional Outcome in Minor Stroke or Transient Ischemic Attack.

Background Oxidized low-density lipoprotein (oxLDL) and hs-CRP (high-sensitivity C-reactive protein) plays an important role in cardiovascular diseases though inflammation and oxidative stress, etc. However, evidence on their combined effects on stroke prognosis is still limited. We aimed to explore the joint association of oxLDL and hs-CRP with outcomes of minor stroke or transient ischemic attack. Methods and Results A subgroup of 3019 patients from the CHANCE trial (Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events) were analyzed. Baseline oxLDL and hs-CRP levels were measured. The primary outcome was any stroke within 90 days. The secondary outcomes included any stroke within 1 year, and ischemic stroke, combined vascular events, and poor functional outcomes (modified Rankin Scale 2-6 or 3-6) at 90 days and 1 year. Vascular events outcomes were analyzed with Cox proportional hazards and poor functional outcomes with logistic models. Elevated oxLDL (>28.81 μg/dL) and hs-CRP (>4.20mg/L) was observed in 624 (20.67%) of the 3019 patients. Patients with oxLDL >28.81 μg/dL and hs-CRP >4.20 mg/L had a higher risk of recurrent stroke within 90 days (adjusted hazard ratio, 1.52; 95% CI, 1.17-1.97), compared with those with oxLDL ≤28.81 μg/dL and hs-CRP ≤4.20 mg/L, after adjusting relevant confounding factors (P=0.002). Similar results were observed for secondary outcomes (P<0.05 for all). Conclusions In patients with minor stroke or transient ischemic attack, joint high levels of oxLDL and hs-CRP was associated with increased risk of recurrent stroke, combined vascular events, and poor functional outcome.

Atrial Cardiomyopathy and Cryptogenic Stroke

Background The frequency of cryptogenic stroke (CS) is about 30% of all cases of ischemic stroke (IS). Patients with CS represent a heterogeneous group of patients and require an individualized approach to antithrombotic therapy for secondary prevention. The frequency of development of repeated acute cerebrovascular events in patients with CS is 4.5% per year, which exceeds this indicator in patients with an established pathogenetic variant of IS. Until recently, the dominant point of view, suggesting that the main cause of CS is paroxysmal atrial fibrillation (AF) and for the secondary prevention of IS in this cohort of patients, oral anticoagulants may be more effective than antiplatelet agents, has not been confirmed. The causal relationship between IS and AF is currently not fully understood. Apparently, AF serves as a marker of atrial cardiomyopathy, which is the direct cause of IS. Aim of study Raising the awareness of neurologists about the causes, pathogenetic mechanisms of development and methods for diagnosing IS in patients with atrial cardiomyopathy. Material and methods To achieve this aim, the results of scientific studies on atrial cardiomyopathy as a risk factor for CS were analyzed. The literature search was carried out in electronic search systems Scopus, eLibrary, PubMed using the keywords: ischemic stroke, cryptogenic stroke, atrial cardiomyopathy, pathogenesis of ischemic stroke. Scientific articles published between 1957 and 2021 were selected to be analyzed. And 36% of the analyzed papers on the topic of CS were published no more than 5 years ago. Conclusion The cumulative evidence suggests that atrial fibrillation is not the only cause of embolic events in patients with evidence of atrial dysfunction. Atrial cardiomyopathy can be the cause of thromboembolic syndrome and cryptogenic stroke, even in the absence of atrial fibrillation, therefore, the latter should be considered as a common manifestation of the underlying atrial cardiomyopathy. Since the majority of cardiac thrombi in patients with atrial fibrillation originate in the left atrium, it is likely that patients with atrial cardiomyopathy and cryptogenic stroke represent a group of patients who may be indicated for anticoagulant therapy as a secondary prevention of ischemic stroke and systemic embolism. However, this hypothesis needs to be confirmed.

Ischaemic events in hypertrophic cardiomyopathy patients with and without atrial fibrillation: a systematic review and meta-analysis.

Hypertrophic cardiomyopathy predisposes to acute cerebrovascular events including ischaemic stroke, transient ischaemic attack and systemic thromboembolism. Atrial fibrillation confers even higher risk. We aim to report the incidence of these complications and to investigate the impact of atrial fibrillation on the ischaemic risk in patients with hypertrophic cardiomyopathy. A literature search was performed on PubMed, Scopus, Embase/Ovid and Cochrane library from inception to 20th March 2021. We compared the incidence of ischaemic strokes, transient ischaemic attack, non-specified thromboembolism events and systemic thromboembolism in hypertrophic cardiomyopathy patients with or without atrial fibrillation. Non-specified thromboembolism events in our paper referred to thromboembolic events whereby types were not specified in the studies. Meta-analysis was performed using StataSE 16 software, and heterogeneity was assessed using I2 test. A total of 713 studies were identified. Thirty-five articles with 42,570 patients were included. The pooled incidence of stroke/ transient ischaemic attack was 7.45% (95% confidence interval [CI] 5.80-9.52, p < 0.001) across 24 studies with a total of 37,643 hypertrophic cardiomyopathy patients. Atrial fibrillation significantly increased the risk of total stroke/ transient ischaemic attack (Risk Ratio 3.26, 95% CI 1.75-6.08, p < 0.001, I2 = 76.0). The incidence of stroke/ transient ischaemic attack was 9.30% (95% CI 6.64-12.87, p = 0.316) in the apical hypertrophic cardiomyopathy subgroup. Concomitant atrial fibrillation in hypertrophic cardiomyopathy increases the risk of thromboembolic events including ischaemic stroke and transient ischaemic attack. The apical subgroup shows a similar risk of acute cerebrovascular events as the overall hypertrophic cardiomyopathy population.