Acute Infarction Research Articles

C-reactive protein after discharge and infarct size in patients with ST segment elevation myocardial infarction

Abstract Background C-reactive protein (CRP) peaks at 2 days in patients with ST-segment elevation myocardial infarction (STEMI) after percutaneous coronary intervention (PCI) and can predict final infarct size. It is, however, unknown whether CRP level after discharge, indicative of prolonged inflammation, plays a prognostic role in myocardial damage. Purpose To investigate the prevalence of high CRP level within 3 months after discharge in patients with STEMI and its association with myocardial damage. Methods In the current study, all patients were identified through the xx database and treated with timely PCI at xx hospital from 2011 to 2014. Blood samples were retrieved within 3 months after discharge. High CRP level was defined as CRP >=3 mg/L. Only patients with a cardiac magnetic resonance (CMR) at baseline or follow-up were recruited. The primary outcome was final infarct size. Multiple regression was performed to adjust for potential confounders using any baseline variable with P<0.10 for the difference between groups. Results Of the 1603 patients from xx, 273 patients had CRP measured following discharge and at least one CMR measured. Of them, 200 (73.3%) had high CRP level after discharge. There was no difference in period from PCI to CRP testing between patients with high CRP and those with low CRP [11 days, interquartile range (IQR) (4, 40) vs. 21 days, IQR (4, 42), P=0.31]. Patients with high CRP level showed larger final infarct size [12.5% left ventricle (LV) vs. 7.0% LV, P <0.001] and larger acute infarct size [15.2% LV vs. 10.6% LV, p=0.004] compared with those with low CRP level. Patients with high CRP level also had lower final myocardial salvage index (MSI) (0.67 vs. 0.75, P=0.003) and lower acute MSI (0.47 vs. 0.61, P=0.006). The results persisted after adjusting for potential confounders in multiple regression. Conclusions A large proportion of patients with STEMI undergoing PCI persisted high CRP within 3 months after discharge. High CRP level after discharge was associated with larger acute and final infarct size as well as lower acute and final MSI level.

Structural-informed functional MRI analysis of patients with empathy impairment following stroke.

The underlying functional alterations of brain structural changes among patients with empathy impairment following stroke remain unclear. We sought to investigate functional connectivity changes informed by brain structural abnormalities in multimodal magnetic resonance imaging (MRI) among patients with empathy impairment following stroke. We enrolled people who had experienced their first ischemic stroke, along with healthy controls. We assessed empathy 3 months after stroke using the Chinese version of the Empathy Quotient (EQ). During the acute phase, all patients underwent basic magnetic resonance imaging (MRI), followed by multimodal MRI during follow-up. Our MRI analyses encompassed acute infarction segmentation, volumetric brain measurements, regional quantification of diffusion parameters, and both region-of-interest-based and seed-based functional connectivity assessments. We grouped patients based on the severity of their empathy impairment for comparative analysis. We included 84 patients who had stroke and 22 healthy controls. Patients had lower EQ scores than controls. Patients with low empathy had larger left cortical infarcts (odds ratio [OR] 4.082, 95% confidence interval [CI] 1.183-14.088), more pronounced atrophy in the right cingulate cortex (OR 1.248, 95% CI 1.038-1.502), and lower scores on the Montreal Cognitive Assessment (OR 0.873, 95% CI 0.74-0.947). In addition, the cingulate cortex served as the seed in the seed-based analysis, which showed heightened functional connectivity between the anterior cingulate gyrus and the right superior parietal lobule, specifically in the low-empathy group. We did not evaluate the relationship between specific network involvement and empathy impairment among patients following stroke. Among patients with subacute ischemic stroke, reduced empathy was strongly associated with a more severe cognitive profile and atrophy of the right cingulate cortex. Our subsequent structural-informed functional MRI analysis suggests that the enhanced connectivity between the anterior cingulate gyrus and the superior parietal lobule may function as a compensatory mechanism for this atrophy.

Redefining Infarction Size for Small-Vessel Occlusion in Acute Ischemic Stroke: A Retrospective Case-Control Study.

Small-vessel occlusion, previously referred to as lacunar infarcts, accounts for approximately one-third of all ischemic strokes, using an axial diameter of less than 20 mm on diffusion-weighted imaging. However, this threshold may not adequately differentiate small-vessel occlusion from other pathologies, such as branch atheromatous disease (BAD) and embolism. This study aimed to assess the clinical significance and pathological implications of acute small subcortical infarctions (SSIs) based on infarct diameter. We conducted a retrospective case-control study using data from stroke patients recorded between 2016 and 2021 of the Stroke Registry in Chang Gung Healthcare System. Patients with acute SSIs in penetrating artery territories were included. Key variables such as patient demographics, stroke severity, and medical history were collected. Infarcts were categorized based on size, and the presence of early neurological deterioration (END) and favorable functional outcomes were assessed. Among the 855 patients with acute SSIs, the median age was 70 years and the median National Institutes of Health Stroke Scale (NIHSS) score at arrival was four. END occurred in 97 patients (11.3%). Those who experienced END were significantly less likely to achieve a favorable functional outcome compared to those who did not (18.6% vs. 59.9%, p < 0.001). The incidence of END increased progressively with infarct sizes of 15 mm or larger, with the optimal threshold for predicting END identified as 15.5 mm and for BAD, it was 12.1 mm. A multiple logistic regression analysis revealed that motor tract involvement [adjusted odds ratio (aOR) 2.3; 95% confidence interval (CI) 1.1-4.7], an initial heart rate greater than 90 beats per minute (aOR 2.3; 95% CI 1.2-4.3), and a larger infarct size (15 mm to less than 20 mm vs. 10 mm to less than 15 mm; aOR 3.0; 95% CI 1.4-6.3) were significantly associated with END. Our findings suggest that setting the upper limit for small-vessel occlusion at 15 mm would be more effective in distinguishing it from BAD. However, these findings should be interpreted in the context of the retrospective design and study population. Further multi-center research utilizing high-resolution vessel wall imaging is necessary to refine this threshold and enhance diagnostic accuracy.

Deep learning reconstruction of diffusion-weighted brain MRI for evaluation of patients with acute neurologic symptoms

Purpose: We aimed to evaluate whether the deep-learning (DL) accelerated diffusion weighted image (DWI) is clinically feasible for evaluating patients with acute neurologic symptoms, regarding its shorter study time and acceptable image quality. Materials and methods: In this retrospective study, brain images obtained at DWI with a b-value of 0 s/mm2 and DWI with a b-value of 1000 s/mm2 (DWI 1000) from 321 consecutive patients with acute stroke-like symptom were reconstructed with and without DL algorithm. We compare the diagnostic performance between DL-DWI and conventional DWI for detecting brain lesions, including acute infarction. We assessed the diagnostic accuracy of conventional DWI and DL-DWI and compared the results. Qualitative analysis based on image quality was assessed and compared using a five-point visual scoring system. Apparent diffusion coefficients (ADCs) from DWI with and without DL were also compared. Results: The mean acquisition time for the DL-DWI (49 s) was significantly shorter (P < 0.001) than conventional DWI (165 s). Both DWI with and without DL showed similar performance in diagnosing brain lesions especially sensitivity (98.8% in both DWI and DL-DWI) and specificity (99.5% in both DWI and DL-DWI). Overall image quality, gray-white matter and deep gray matter differentiation of two sequences were similar. DL DWI showed more artifacts than DWI. Lesion conspicuity, especially smaller than 5 mm, was better with DL DWI than conventional DWI (p = 0.03). ADC values of white matter, deep gray matter, and pons with DL were lower than conventional DWI. Conclusions: Compared to conventional DWI, DL-DWI achieved comparable image quality and brain lesion visualization for acute neurological symptoms, with a significantly shorter scan time.

Acute Cerebellar Infarct in A Patient with Undiagnosed Fahr’s Syndrome: A Case Report

Introduction: Fahr’s disease and Fahr’s syndrome represent clinical entities that result in diffuse intracranial brain calcification, either by way of genetic mutation in the case of the former or by secondary endocrine dysfunction in the latter. Case Report: We present a case of a middle-aged male with undiagnosed Fahr’s syndrome, identified during evaluation for symptoms of an acute posterior circulation cerebrovascular accident. Conclusion: Fahr’s syndrome is a clinical constellation of symptoms and radiographic findings often seen in late-stage hypoparathyroidism. The intracranial calcifications associated may be related to an increased risk for intracranial cerebrovascular disorders such as ischemic or hemorrhagic infarct. Keywords: Fahr’s syndrome; case report; posterior circulation stroke; cerebellar infarct.

The important role of ferroptosis in inflammatory bowel disease.

Ferroptosis is a type of regulated cell death that occurs due to the iron-dependent accumulation of lethal reactive oxygen species (ROS) from lipids. Ferroptosis is characterized by distinct morphological, biochemical, and genetic features that differentiate it from other regulated cell death (RCD) types, which include apoptosis, various necrosis types, and autophagy. Recent reports show that ferritin formation is correlated to many disorders, such as acute injury, infarction, inflammation, and cancer. Iron uptake disorders have also been associated with intestinal epithelial dysfunction, particularly inflammatory bowel disease (IBD). Studies of iron uptake disorders may provide new insights into the pathogenesis of IBD, thereby improving the efficacy of medical interventions. This review presents an overview of ferroptosis, elucidating its fundamental mechanisms and highlighting its significant involvement in IBD.

A diagnosis that’s hard to swallow: case report of delayed onset lateral medullary syndrome presenting with only dysphagia

BackgroundLateral Medullary Syndrome (LMS) is a posterior circulation stroke (PCS) that has a broad array of manifestations but most classically presents with Horner’s syndrome, ipsilateral ataxia, and ipsilateral hyperalgesia. Although dysphagia is also common, isolated and single presentation of this alone is rare and there are only a few case reports of this in the literature. This presentation can bias a clinician’s differential diagnosis and delay diagnosis.Case presentationA previously healthy 53-year-old-male presented with a complaint of dysphagia. He had no PCS symptoms, a National Institute of Health Stroke Scale (NIHSS) of zero, and an otherwise unremarkable neurological exam. Stroke imaging including non-contrast computed tomography (NCCT) scan of his head and computed tomography angiography (CTA) scan of his head and neck revealed no acute abnormalities. He was found to be positive for Influenza A, but otherwise all other etiologies for his dysphagia were worked up, including consultation with other specialty services, without resolve. Two days later, the patient subsequently developed new right sided sensory deficits and left sided Horner’s syndrome, in which a magnetic resonance imaging (MRI) scan of his head revealed an acute infarct of the left lateral medulla with likely thrombus in the left posterior inferior cerebellar artery (PICA).ConclusionsPCS is frequently missed due to the often-vague symptoms and reassuring negative imaging. This case highlights the variability of presentations that ED physicians may encounter. Nonetheless, a high index of suspicion for PCS should be maintained even in young patients without risk factors. Lastly, dysphagia is never normal, and this case demonstrates the need to reconsider neurogenic origin when other causes have been ruled out.

7087 An Unusual Movement Disorder, Case of Diabetic Striatopathy!

Abstract Disclosure: S. Azmat: None. O. Lodhi: None. R. Safi: None. H. harb: None. H. Ashok: None. M.F. Siddiqui: None. J.L. Gilden: None. Background: Non-ketotic Hyperglycemia Hemichorea-Hemiballismus Syndrome (NKH-CB) is rare complication of poorly controlled diabetes mellitus (DM) characterized by continuous, irregular jerky movements localized to one side of the body. It is commonly seen in type 2 DM and is often presented in females of East Asian descent. NKH-CB is often misdiagnosed due to its rarity and radiographic features easily mistaken for intracerebral hemorrhage.Case: A 70-year-old Latino male with type 2 diabetes mellitus, hypertension, bipolar disorder and past history of two cerebrovascular accidents presented to ED with non-radiating, midsternal chest pain. ACS was ruled out with negative serial troponins and normal EKG. Vital signs were significant for elevated blood pressure 151/64 mmHg. Labs showed blood glucose=447 mg/dL. Physical examination revealed large amplitude involuntary movements in left upper and lower extremities and facial region. He also veered to the left when ambulating. The patient reported that these abnormal movements were occurring for last three weeks although sensation was preserved bilaterally. Code stroke was called; non-contrast CT showed unilateral hyper density of the right caudate and putamen with no evidence of acute intracranial hemorrhage or large arterial territory infarction. CT Angiogram did not show any signs of stenosis or occlusion. He received intravenous fluids and 8 units lispro insulin in ED. Was admitted for further evaluation and received basal/bolus insulin therapy with target blood glucose of 140-160 mg%. He also received risperidone for his mental condition. Subsequent testing revealed hemoglobin A1C of 16.9% (reference range: &amp;lt; 5.7%). MRI Brian showed unilateral T1 hyperintensity involving right caudate and putamen corresponding to the hypodensity seen on CT. Neurology service was consulted. Based on clinical signs/symptoms coupled with neuroimaging, he was diagnosed with non-ketotic Hyperglycemia Hemichorea-Hemiballismus Syndrome. On day 2 with resolution of hyperglycemia, amplitude and frequency of involuntary arm movements were minimal. The patient was discharged with Lantus 7 and metformin 1000 mg for DM and risperidone for symptoms management. Conclusion: Diabetic neuropathy is commonly known to result in small and/or large fiber sensorimotor polyneuropathy, proximal motor, and acute mononeuropathies as well as entrapments, radiculopathies, autonomic neuropathies, and even cognitive disorders. This case describes rare case of simultaneous NKH-CB with history of CVA and antipsychotic medication use in a patient with poorly controlled DM which resolved with treatment of hyperglycemia. Thus offers valuable insights into the diagnostic challenges associated with this condition as well as potential links to other neurological complications. One should also remain vigilant of potential onset of seizures commonly seen with NKH. Presentation: 6/3/2024

8291 Graves’ Disease and Moyamoya Syndrome: A Complex Case of Thyroid Dysfunction and Neurovascular Abnormalities

Abstract Disclosure: A. Jamil: None. Q.V. Luong: None. A. Llorens Bonilla: None. A. Siddiqui: None. Background: Moyamoya disease is a cerebrovascular disease characterized by progressive stenosis and occlusion of cerebral arteries, particularly the internal carotid arteries, proximal anterior and middle cerebral arteries associated with a net-like collateral vessel formation. Moyamoya disease in association with certain systemic conditions (e.g. Graves’ disease, sickle cell anemia, neurofibromatosis type 1, and Down Syndrome) has been referred to as moyamoya syndrome. Graves’ disease is an autoimmune disease in which the development of thyroid-stimulating hormone (TSH) receptor autoantibodies leads to overproduction of thyroid hormones. Although the pathophysiology is unclear, Graves’ disease can adversely impact the clinical course of moyamoya syndrome.Clinical Case: A 26-year-old woman diagnosed with Graves’ disease at the age of 20 years who was in remission presented to the ED with right upper extremity weakness and headache. A stroke work-up was performed, and an initial CT head without contrast showed an acute infarct in the left temporal area. Extensive workup for hypercoagulability and cardiac causes were negative. MRI brain showed multiple infarcts of the left cerebral hemisphere with ivy sign, which are prominent linear or punctate high intensity areas in the subarachnoid space reflecting the development of collaterals that occurs in moyamoya disease. TSH at the time was noted to be &amp;lt;0.01 uIU/mL (range: 0.30-4.20 uIU/mL), indicating a thyrotoxic state. She was discharged on methimazole and antiplatelet therapies. However, the patient continued to have hypertension and headaches which did not resolve with the return to euthyroidism. At age 29, she again developed acute right upper and lower extremity weakness, and consequently presented to the ED. Imaging studies showed multiple punctate infarcts in her bilateral frontal lobes and bilateral ICA stenosis consistent with moyamoya disease. However, her biochemical studies showed euthyroidism. Ultimately, she underwent right frontotemporal craniotomy and direct parietal superficial temporal artery to middle cerebral artery bypass by neurosurgery to decrease her future stroke risk for her moyamoya syndrome, and her Graves’ disease remains in remission.Conclusions: The coexistence of Graves’ disease in moyamoya syndrome may suggest a pathophysiologic connection. It has been suggested that hemodynamic changes in cerebrovascular flow due to thyrotoxicosis might contribute to ischemic neurologic deficits. Surgical intervention for revascularization procedures should be attempted after optimal control of thyrotoxicosis, as this may help to prevent further ischemic events in the future and improve patient outcomes. Presentation: 6/1/2024

Baseline Blood Pressure Was Associated with Hemispheric Cerebral Blood Flow in Acute Small Subcortical Infarcts

Introduction: While increased baseline blood pressure (BP) is a prevalent comorbidity in the acute phase of ischemic stroke, the association between baseline BP and the state of hemispheric perfusion in patients with acute small subcortical infarcts (SSIs) has not been studied in detail. The aim of this study was to investigate the relationship between baseline BP and hemispheric cerebral blood flow (CBF) in acute SSIs. Methods: This retrospective study included 101 patients with acute SSIs. Baseline hemispheric CBF was assessed through co-registration of baseline CT perfusion imaging and follow-up diffusion-weighted imaging. The association between baseline BP, CBF, and different cerebral small vessel disease (CSVD) biomarkers was assessed. Results: Baseline systolic BP (SBP) and diastolic BP (DBP) were negatively associated with contralateral hemispheric CBF after multivariate-adjusted linear analysis (SBP: β = −0.001, 95% CI: −0.002 to 0.000, p = 0.030; DBP: β = −0.002, 95% CI: −0.003∼0.001, p = 0.006). Among other CSVD biomarkers, the presence of any cerebral microbleeds showed a significant association with lower CBF in the contralateral hemisphere of the infarct lesion (r = −0.270, p = 0.035). Conclusion: In patients with acute SSIs, increased baseline BP was associated with reduced CBF in the contralateral hemisphere of the infarct lesion, which probably could be interpreted by the exacerbation of the CSVD burden, suggesting a potential mechanistic link between BP autoregulation dysfunction and the aggravation of neurovascular impairment in SSIs.

68Ga-FAPI PET in Visualizing Acute Ischemic Stroke at Risk of Hemorrhagic Transformation.

Hemorrhagic transformation is a serious complication of ischemic stroke, which occurs at a rate of between 18% and 42%. 68Ga-FAPI PET can visualize acute cerebral infarction at risk of hemorrhagic transformation in the brain. We report a case of 68Ga-FAPI PET imaging in a patient with recurrent ischemic stroke. 68Ga-FAPI PET imaging revealed FAPI uptake in acute ischemic stroke with hemorrhagic transformation, but did not in some acute infarction and chronic infarction without hemorrhagic transformation. These findings suggest potential role of 68Ga-FAPI PET in the evaluation of acute ischemic stroke with the risk of hemorrhagic transformation.

Intraplaque hemorrhage volume in patients with carotid atherosclerosis: How informative is it?

Background and purposeIntraplaque hemorrhage (IPH) of carotid atherosclerosis is an important feature in complex lesions preceding acute stroke events. The current study aimed to determine the role played by IPH volume compared to that of carotid stenosis or maximal wall thickness in patients with carotid IPH. Materials and methodsThis retrospective study included 233 patients who presented with carotid IPH on vessel wall imaging (VWI). We divided the patients into symptomatic or asymptomatic groups based on territorial acute focal infarction. The IPH volume, degree of stenosis, and maximal wall thickness on VWI were analyzed. ResultsOf the 233 included patients with carotid IPH, 51 (21.9%) patients showed initial clinical symptoms and positive territorial findings on diffusion-weighted imaging (DWI). Moreover, 154 (66.1%) patients had low-grade stenosis below 50% (n = 19: symptomatic groups). Overall, carotid IPH volume, degree of stenosis, and maximal wall thickness were all significantly higher in the symptomatic groups (p = 0.001). The degree of stenosis, in all patients and especially in those with high-grade stenosis above 50%, was significantly correlated with territorial acute focal infarction on multivariate analysis (p < 0.01). In patients with low-grade stenosis below 50%, maximal wall thickness was associated with territorial acute focal infarction (p = 0.48). ConclusionCarotid IPH volume was a risk factor for territorial acute focal infarction. However, in patients with high-grade stenosis, the degree of stenosis was significantly linked to acute stroke. By contrast, in patients with low-grade stenosis, maximal wall thickness exhibited a significant association with acute stroke.

Unveiling Benedikt’s syndrome: A rare midbrain stroke presenting with oculomotor nerve palsy

A 34-year-old female presented to the neuro-ophthalmology outpatient department with the primary complaint of ptosis of the right eyelid experienced over the course of 3 days. Clinical evaluation unveiled a right oculomotor nerve palsy, accompanied by compromised motor function in the left upper and lower extremities. Neuroimaging studies subsequently revealed the presence of an acute non-hemorrhagic infarct localized within the right paramedian midbrain region, specifically encompassing the red nucleus and the oculomotor nerve fascicles, a presentation conclusively indicative of Benedikt’s syndrome.

Brown-Séquard syndrome after a. spinalis posterior infarction

Spinal cord infarction is an infrequent event, and the occurrence of Brown-Séquard syndrome resulting from spinal cord infarction is even rarer. In this case report, a 55-year-old woman presented with sudden onset of back pain and a right-sided Brown-Séquard syndrome. MRI of the spinal cord revealed acute infarction in the right posterior spinal artery at Th5-Th10. In case of sudden Brown-Séquard syndrome, the possibility of a spinal cord infarction should be considered.

Efficacy of Proprioceptive Neuromuscular Facilitation on Jaw Function in Bruxism Among Post Stroke Survivor: A Case Study

A 49-year-old male who was a known case of Type 2 diabetes mellitus and hypertensive had a history of an acute infarct in the left ganglia capsular region and a chronic infarct in the left parieto-occipital lobe, which was conservatively managed and was referred for physiotherapy rehabilitation for strengthening the right upper and lower limb. During the physiotherapy intervention, abnormal teeth grinding was observed, and the patient was asked about parafunctional behaviour. Upon examination, there was a restriction in the jaw range of motion assessed by measuring the jaw range using the vernier caliper and tightness in the masticatory muscle, as evidenced by palpating the masseter muscle. Proprioceptive neuromuscular facilitation and ultrasound therapy were given for 1 session per week for 2 weeks to treat bruxism along with standardized stroke protocol. At the end of 2 weeks after the intervention, there was an increase in jaw opening and reduced masticatory muscle activity. Jaw opening was measured using a vernier caliper, and masticatory activity was measured using electromyography of the masseter and temporalis muscles. This study suggests the importance of treating bruxism to prevent complications related to it. It concludes that proprioceptive neuromuscular facilitation and ultrasound therapy were effective in improving mouth opening and reducing the masticatory activity in bruxism among stroke patients with ganglia capsular involvement.

Diagnostic Challenges in Identifying Atrial Myxoma as a Cause of Transient Ischemic Attacks: A Case Report

Abstract Background A 67-year-old woman presented to hospital on multiple occasions with transient neurological symptoms over a period of 20 months. Initial diagnostics, including computed tomography (CT), carotid Dopplers, and electrocardiogram, were unremarkable. Magnetic resonance imaging (MRI) was arranged following the third neurological event which revealed multi-territory acute ischemic events, suggestive of a cardioembolic source. Transoesophageal echocardiography identified a large mobile atrial myxoma, histologically confirmed. Atrial myxoma, though rare, is an important cause of thromboembolic stroke, underscoring the need for comprehensive cardiac evaluation in cerebrovascular incidents. Methods The patient's case was reviewed, focusing on initial presentations, diagnostic workup, and subsequent management. Initial presentations included transient visual disturbances and transient leg weakness. Routine tests were conducted, including CT brain, carotid Dopplers, and blood tests. MRI and transoesophageal echocardiography were performed which ultimately identified the underlying cause of the patient’s neurological events. Results Initial evaluations (CT, carotid Dopplers) were normal. An MRI performed 20 months after her initial presentation revealed small acute infarcts in the right cerebellar hemisphere and left superior parietal lobe. Transoesophageal echocardiography subsequently detected a large atrial myxoma. The patient's transient symptoms and negative initial workup delayed the diagnosis, highlighting the necessity of including cardiac imaging early in the stroke workup, especially in cases of suspected cardioembolic events. Conclusion This case illustrates the critical role of thorough cardiac evaluation, including echocardiography, in diagnosing the cause of transient ischemic attacks (TIA) and strokes. The patient’s initial negative findings delayed the identification of a cardioembolic source, emphasizing the importance of comprehensive diagnostic protocols for suspected cerebrovascular events. Urgent surgical resection is essential for atrial myxoma to prevent recurrent embolic events. This report highlights the diagnostic and management challenges of cardiac myxomas, advocating for a more rigorous approach to stroke evaluation and timely intervention.

Acute atrial infarction: arelatively neglected and under-recognized entity in clinical practice.

Electrocardiograms (ECGs) and angiographic features indicative of acute atrial infarction (AAI) often go unnoticed and are under-recognized in clinical practice. In this retrospective observational study, we analyzed the data of 3981 out of 9803 patients (40.61%) who were referred to our hospital for angiography and/or percutaneous coronary intervention due to acute coronary syndrome (ACS). These patients were diagnosed with acute ST segment elevation myocardial infarction (AMI) affecting the inferior, posterior, and/or right ventricular regions. Of the 3981 patients, 270 (6.78%) had involvement of the main coronary atrial branch meeting the angiographic criteria for AAI. Among the 270 patients identified, the right coronary artery was diagnosed as the infarct-related artery (IRA) in 187 patients (groupR), while the left circumflex artery was the IRA in 83patients (groupL). The incidence of PR-segment deviation was similar between the two groups (65.2% in groupR vs.66.3% in groupL, p = 0.870), as was occurrence of atrial tachyarrhythmia (67.4% vs.55.4%, p = 0.059). The prevalence of P wave morphology abnormalities (29.9% vs.49.4%, p = 0.005) and sinus bradycardia or arrest (25.1% vs.66.3%, p < 0.001) was significantly lower in GroupR than in GroupL. Acute atrial infarction represents adistinct yet frequently overlooked clinical entity. Clinicians should consider the potential for atrial arrhythmias, thromboembolism, hemodynamic instability, and atrial rupture when diagnosing AAI.

In silico evaluation of cell therapy in acute versus chronic infarction: role of automaticity, heterogeneity and Purkinje in human

Human-based modelling and simulation offer an ideal testbed for novel medical therapies to guide experimental and clinical studies. Myocardial infarction (MI) is a common cause of heart failure and mortality, for which novel therapies are urgently needed. Although cell therapy offers promise, electrophysiological heterogeneity raises pro-arrhythmic safety concerns, where underlying complex spatio-temporal dynamics cannot be investigated experimentally. Here, after demonstrating credibility of the modelling and simulation framework, we investigate cell therapy in acute versus chronic MI and the role of cell heterogeneity, scar size and the Purkinje system. Simulations agreed with experimental and clinical recordings from ionic to ECG dynamics in acute and chronic infarction. Following cell delivery, spontaneous beats were facilitated by heterogeneity in cell populations, chronic MI due to tissue depolarisation and slow sinus rhythm. Subsequent re-entrant arrhythmias occurred, in some instances with Purkinje involvement and their susceptibility was enhanced by impaired Purkinje-myocardium coupling, large scars and acute infarction. We conclude that homogeneity in injected ventricular-like cell populations minimises their spontaneous beating, which is enhanced by chronic MI, whereas a healthy Purkinje-myocardium coupling is key to prevent subsequent re-entrant arrhythmias, particularly for large scars.

Acute Renal Infarction: A 12-Year Retrospective Analysis

Introduction: Acute renal infarction (ARI) is a relatively rare and underdiagnosed condition. Presenting symptoms are nonspecific, and imaging is the mainstay for diagnosis. This study attempts to characterize the profile of patients with ARI and identify possible risk factors. Methods: All inpatients admitted with diagnosis of ARI between 2010 and 2022 were included in this single-center retrospective observational study. Patients with chronic renal infarction, iatrogenic causes, and without radiographic evidence of ARI were excluded. Clinical, laboratory, and radiological findings of patients were collected. Patients were grouped into three groups based on probable etiology: cardiovascular, hypercoagulable disorders, and idiopathic, and analyzed. Results: Eighty-five patients were included. Mean age of patients was 61.6 ± 17.54 years. Cardiovascular group had the highest number of patients (49.4%) of which atrial fibrillation was the most common etiology (59.5%). Malignancy was the most common etiology in the hypercoagulable disorder group (69.3%). Patients in the idiopathic group were significantly younger and had higher mean body mass index than the other 2 groups at presentation. Smokers had 9 times higher risk of renal infarction in cardiovascular group and 1.7 times higher risk in hypercoagulable when compared to the idiopathic group. 48.2% of patients developed renal infarction though they were on antiplatelets/anticoagulants. Conclusion: ARI is a rare and often underdiagnosed condition that can have residual renal dysfunction. It is important to consider ARI as a differential especially in young patients with risk factors even if they are on anticoagulation medication.

NeuroMix with MRA: A Fast MR Protocol to Reduce Head and Neck CTA for Patients with Acute Neurologic Presentations.

Overuse of CT-based cerebrovascular imaging in the emergency department and inpatient settings, notably CTA of the head and neck for minor and nonfocal neurologic presentations, stresses imaging services and exposes patients to radiation and contrast. Furthermore, such CT-based imaging is often insufficient for definitive diagnosis, necessitating additional MR imaging. Recent advances in fast MRI may allow timely assessment and a reduced need for head and neck CTA in select populations. We identified inpatients or patients in the emergency department who underwent CTAHN (including noncontrast and postcontrast head CT, with or without CTP imaging) followed within 24 hours by a 3T MRI study that included a 2.5-minute unenhanced multicontrast sequence (NeuroMix) and a 5-minute intracranial time of flight MRA) during a 9-month period (April to December 2022). Cases were classified by 4 radiologists in consensus as to whether NeuroMix and NeuroMix + MRA detected equivalent findings, detected unique findings, or missed findings relative to CTAHN. One hundred seventy-four cases (mean age, 67 [SD, 16] years; 56% female) met the inclusion criteria. NeuroMix alone and NeuroMix + MRA protocols were determined to be equivalent or better compared with CTAHN in 71% and 95% of patients, respectively. NeuroMix always provided equivalent or better assessment of the brain parenchyma, with unique findings on NeuroMix and NeuroMix + MRA in 35% and 36% of cases, respectively, most commonly acute infarction or multiple microhemorrhages. In 8/174 cases (5%), CTAHN identified vascular abnormalities not seen on the NeuroMix + MRA protocol due to the wider coverage of the cervical arteries by CTAHN. A fast MR imaging protocol consisting of NeuroMix + MRA provided equivalent or better information compared with CTAHN in 95% of cases in our population of patients with an acute neurologic presentation. The findings provide a deeper understanding of the benefits and challenges of a fast unenhanced MR-first approach with NeuroMix + MRA, which could be used to design prospective trials in select patient groups, with the potential to reduce radiation dose, mitigate adverse contrast-related patient and environmental effects, and lessen the burden on radiologists and health care systems.