Acute Ischemic Infarction Research Articles

ACUTE MULTIPLE CEREBRAL WATERSHED INFARCTIONS AS THE FIRST PRESENTATION OF COVID-19 IN A YOUNG MALE PATIENT: A CASE REPORT

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Novel Coronavirus disease 2019 (COVID-19) pandemic represents the greatest global public health crisis since the influenza outbreak in 1918. It has been associated with hypercoagulability causing life-threatening cardiovascular and neurovascular complications. The pathogenesis of this predisposition is not well understood, and one of its consequences is an increased risk of stroke. Patients with patent foramen ovale (PFO), atrial fibrillation, previous history of stroke, and elderly patients with uncontrolled hypertension, may be at a higher risk of developing strokes with COVID-19. We present a rare case of acute multiple cerebral watershed infarctions in a COVID-19 patient. CASE PRESENTATION: 38 year-old obese male with past medical history of hypertension presented with confusion, left sided weakness, right lower extremity weakness, and right gaze preference. MRI brain demonstrated multiple patchy small areas of acute ischemic infarcts bilaterally consistent with watershed infarcts. An echocardiogram with bubble study was negative for PFO. Lower extremity venous Doppler ultrasound was negative for DVT. Telemetry didn't record any arrhythmias. Laboratory work-up ruled out autoimmune diseases, hypercoagulable states, and vasculitis including: antiphospholipid antibodies, lupus anticoagulants, anti-neutrophil cytoplasmic antibodies, anti-nuclear antibodies, anti-factor Xa, Anti-thrombin, Protein S and C, and rapid plasma regain. The patient was screened for COVID-19 due to increased reports of stroke in young patients nationwide, and surprisingly, the test was positive. Aspirin, clopidogrel, high-intensity statins, along with enoxaparin for DVT prophylaxis were initiated. DISCUSSION: Evidence increasingly shows that COVID-19 it is not always confined to the respiratory tract but can also induce neurologic diseases with increased risk of stroke in young patients. The reported incidence of stroke in COVID-19 positive patients is about 1-6%. The plausible proposed mechanisms include: viral neurotropism, coagulopathy from systemic inflammation and cytokine storm, and endothelial dysfunction leading to angiopathic thrombosis. There are handful of cases linking COVID-19 to large vessel macrothrombosis and antiphospholipid syndrome. We herein report an even more unusual case that presented with multiple focal neurologic symptoms and was found to have watershed infarctions secondary to COVID-19 with only mild respiratory symptoms, without typical vascular risk factors, PFO or arrhythmia, after excluding autoimmune diseases, hypercoagulability diseases, and vasculitis, shedding the light on the importance of suspecting this devastating disease in an otherwise healthy young patient who presents with focal neurological symptoms. CONCLUSIONS: In COVID-19 patients with mild respiratory symptoms, a low threshold for investigation for stroke should be adopted with any new neurological symptoms. REFERENCE #1: Tan YK, Goh C, Leow AST, et al. COVID-19 and ischemic stroke: a systematic review and meta-summary of the literature. J Thromb Thrombolysis. 2020;50(3):587-595. doi:10.1007/s11239-020-02228-y DISCLOSURES: No relevant relationships by Ramy Abdelmaseih, source=Web Response No relevant relationships by Randa Abdelmasih, source=Web Response

A DRAMATIC PRESENTATION OF A CARDIAC MYXOMA

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cardiac myxoma is the most frequent primary cardiac neoplasm, nonetheless, the cardiac tumor is very rare.1 The diagnosis of these tumors can be incidental or due to symptoms secondary to complications, like embolization, or valvular dysfunction.2 The management will depend on the size and characteristic of the mass. Embolic stroke is a dramatic and severe complication of cardiac myxoma.2,3 CASE PRESENTATION: A 31 year-old female with a PMHx of well controlled Crohn's disease, presented to our institution via helicopter for a higher level of care, after receiving TPA for an ischemic stroke. A mechanical thrombectomy was planned and her NIHSS was 9. After she arrived, a CT cerebral perfusion scan showed an acute ischemic infarction in the territory of the right MCA with right superior M2 occlusion. There was a mild mass effect on the right lateral ventricle without evidence of brain herniation. The patient was started on NS 3% and mannitol.On the 2nd day of hospitalization the patient suddenly desaturated requiring emergent intubation. A chest x-ray demonstrated flash pulmonary edema. The patient's mechanical ventilation was optimized for ARDS and she was turned prone. On the same day the patient was started on multiple pressors. On day 3 a copious amount of clear fluid was suctioned from the ET tube, analyzed as transudate with no signs of infection.The patient's cerebral edema also worsened and a right decompressive craniectomy was required. The patient began to go into multiorgan failure due to continued hypoperfusion. Her LFTs trended upwards as her kidney function declined. On day 4 an Echocardiogram showed a normal left ventricular size with decreased EF 25%-30%. A large mobile mass was attached to the interatrial septum obstructing the mitral valve with moderate mitral regurgitation and pulmonary hypertension. This mass was suggestive of an atrial myxoma. CT surgery was immediately consulted, intervention was scheduled for the following day. Unfortunately the patient coded the same day after she was turned from prone to supine. Multiple rounds of CPR were performed, however the patient expired. DISCUSSION: We suspect that the change in position caused increased outflow obstruction by the myxoma resulting in cardiac arrest. Due to the large size of the mass and the rapid progression of the patient's symptoms, it is unlikely an early diagnosis would have significantly changed her prognosis. CONCLUSIONS: The severe and dramatic presentation of this case, showed the relevance of this rare pathology and the devastating consequences of the natural course of this disease. In a retrospective analysis of the case, no personal history suggested this diagnosis. In the setting of a sudden ischemic stroke shortly followed or accompanied by flash pulmonary edema, should arouse clinical suspicions for some embolic pathology that may be causing outflow obstruction such as an atrial myxoma. REFERENCE #1: El Sabbagh, Abdallah et al. "Cardiac Myxoma: The Great Mimicker." JACC. Cardiovascular imaging 10.2 (2017): 203–206. Web. REFERENCE #2: Vontobel, Jan, Martin Huellner, and Paul Stolzmann. "Cerebral 'Metastasizing' Cardiac Myxoma." European heart journal 37.21 (2016): 1680–1680. Web. REFERENCE #3: Saddoughi, Sahar A., Joseph J. Maleszewski, and Hartzell V. Schaff. "Cardiac Myxoma: Simplifying a 'Complex' Case." The Journal of thoracic and cardiovascular surgery 152.5 (2016): 1439–1440. Web. DISCLOSURES: No relevant relationships by Javier Cabello Garza, source=Web Response No relevant relationships by Heriberto Cantu, source=Web Response No relevant relationships by Zachary Keatts, source=Web Response No relevant relationships by Ismael Polo Perez, source=Web Response

Cardio-cerebral infarction in left MCA strokes: a case series and literature review

The objective of this manuscript is to describe the challenges of Cardio-Cerebral Infarction (CCI) treatment and to highlight the variable approaches in management. CCI is a rare clinical presentation of simultaneous acute ischemic stroke (AIS) and acute myocardial infarction (AMI) and poses a therapeutic challenge for practitioners. Each disease requires timely intervention to prevent irreversible damage; however, optimal management remains unclear. We describe three cases of CCI. All three patients presented with symptomatic left MCA (M1) occlusion, with ST elevation myocardial infarction (STEMI) and left ventricular apical thrombus. Fibrinolysis and mechanical thrombectomy (MT) were discussed in all cases, but only one patient received alteplase (0.9 mg/kg) and none underwent MT. Percutaneous intervention (PCI) was done in only one case. The two patients that did not receive thrombolysis were treated with modified therapeutic heparin (no bolus), and all received antiplatelet therapy. Ultimately, all three patients passed away. CCI poses a clinical challenge for physicians including (1) optimal strategies to enable swift mechanical reperfusion to both the brain and myocardium; (2) difference in dosage of thrombolytics for AIS versus AMI; (3) risk of symptomatic intracerebral hemorrhage following administration of anticoagulation and/or antiplatelet therapy; and (4) caution with use of thrombolytics in the setting of acute STEMI due to the risk of myocardial rupture. In the absence of high quality evidence and clinical guidelines, treatment of CCI is highly individualized.

Acute brucellosis associated with isolated splenic and left gastric artery vasculitis and acute ischemic bowel infarction. A systematic review of the most recent cases

Brucellosis is a multisystem bacterial zoonosis caused by Gram-negative bacteria Brucella spp. Ingestion of infected food products, direct contact with an infected animal, or inhalation of aerosols are all ways for germs to spread from animals to humans. Intestinal vasculitis with gangrene due to brucellosis has rarely been reported. We report a 62-year-old male patient presenting with acute onset of recurrent attacks of abdominal pain, remittent fever, malaise, and weight loss, which were followed by severe left hypochondrium abdominal pain with rigidity and signs of acute abdomen. Brucellosis was clinically suspected and confirmed by an enzyme-linked immunosorbent assay against the Brucella melitensis species. An abdominal CT scan revealed isolated splenic and left gastric artery vasculitis, leading to acute bowel ischemia, bowel infarction and gangrenous jejunal bowel segment. Histopathological examination of the resected gangrenous bowel segment revealed leucocytoclastic vasculitis. The patient was successfully treated with a standardized antimicrobial therapy for brucellosis and a short course of steroids with a complete resolution of the symptoms and signs. The case is discussed and the literature is reviewed.

Effectiveness of Continuous Hypertonic Saline in Acute Ischemic Infarcts: A Radiographic and Clinical Evaluation

The role of continuous hypertonic saline (HS) infusion in the management of malignant cerebral edema is controversial. We evaluated patients presenting with large anterior circulation territory infarcts and compared radiographic and clinical outcomes to evaluate the effects of continuous HS. This was a retrospective review of patients with malignant ischemic strokes who were initially managed with continuous HS versus routine medical management. Radiographic parameters of cerebral edema and clinical parameters were collected at different time intervals after admission. Rates and timing of surgery, mortality, and complications were also collected. The study included 43 patients: 26 in group 1 (HS) and 17 in group 2 (no HS). Both cohorts had comparable baseline clinical and radiographic parameters. There was no difference between rates and timing of surgery, complications, and mortality. Mean midline shift was significantly greater in the HS group at interval 1 (12-36 hours, P= 0.003) and interval 2 (36-60 hours, P= 0.030), and mean change in midline shift from initial interval to interval 1 was significantly greater in the HS group (P= 0.019). Despite the widespread use of continuous HS in acute ischemic infarcts, only a limited number of studies have evaluated its efficacy, and virtually no studies have studied its effect on radiographic progression and rates of decompressive surgery. Results of this study indicate that there is no benefit of continuous HS. In fact, there may be worsening of cerebral edema with administration of continuous HS. In addition, there are no differences in prevention or delay of decompressive surgery or in overall mortality.

Quasi Moyamoya Disease: Case report and literature review

Quasi moyamoya disease is the unilateral form of typical moyamoya disease which is associated with acute or chronic stages of inflammatory diseases. Here, I present 21-year-old boy presented with sudden onset of weakness of right sided limbs following physical workout, had acute ischemic infarction of left internal capsule in diffusion restriction MR image and unilateral steno- occlusive changes of terminal portion of left internal carotid artery was noted in digital subtraction angiography.

Predictive Value of CT Brain Perfusion Studies in Acute Ischemic Infarct Taking MRI Stroke Protocol As Gold Standard.

BackgroundAcute ischemic stroke is the leading cause of serious chronic disability worldwide. Imaging plays a key role in early diagnosis and intervention, thus reducing mortality and morbidity related to ischemic stroke. Computed tomography (CT) perfusion study is a valuable imaging tool for the assessment of acute infarction. The objective of this study was to determine the predictive value of CT perfusion in diagnosing acute ischemic infarction taking Magnetic Resonance Imaging (MRI) stroke protocol (including Diffusion Weighted Imaging (DWI)) as a gold standard.MethodsThe cross-sectional validation study was conducted at a teaching hospital in Islamabad from June 2019 to December 2019. The study comprised a total of 125 patients of either gender with suspected acute ischemic stroke. The patients were scanned for CT perfusion and MRI stroke protocol on the same day. Scans were reported separately for the detection of acute ischemic infarction by the same consultant radiologist. The predictive value of CT perfusion was calculated accordingly.ResultsOf the 125 patients, 58% were male and 42% were female. The age of selected patients ranged between 38 to 70 years with a mean age of 56.12 ± 9.69 years. Acute ischemic infarction was detected in 86 (69%) patients by CT perfusion study and in 120 (96%) patients by MRI stroke protocol. The positive predicted value of CT perfusion for the detection of acute infarction was calculated as 98.83 and the negative predicted value was 10.25.ConclusionCT perfusion study provides adequate sensitivity and specificity with good predictive value in the detection of acute ischemic infarct in stroke patients. This widely available and time-effective modality aids in the triage of patients for immediate endovascular intervention leading to maximal neurological benefit and improving outcomes.

Risk of Mortality After an Arterial Ischemic Event Among Intracerebral Hemorrhage Survivors.

The impact of arterial ischemic events after intracerebral hemorrhage (ICH) on outcomes is unclear. This study aimed to evaluate the risk of death among ICH survivors with and without an incident arterial ischemic event. We performed a retrospective cohort study using claims data from Medicare beneficiaries with a non-traumatic ICH from January 2008 to October 2015. Our exposure was an arterial ischemic event, a composite of acute ischemic stroke or myocardial infarction (MI), identified using validated ICD-9-CM diagnosis codes. The outcome was mortality. We used marginal structural models to analyze the risk of death among ICH patients with and without an arterial ischemic event, after adjusting for confounders as time-varying covariates. Among 8,804 Medicare beneficiaries with ICH, 2,371 (26.9%) had an arterial ischemic event. During a median follow-up time of 1.9 years (interquartile range, 0.7-3.9), ICH patients with an arterial ischemic event had a mortality rate of 21.7 (95% confidence interval [CI], 20.4-23.0) per 100 person-years compared to a rate of 15.0 (95% CI, 14.4-15.6) per 100 person-years in those without. In the marginal structural model, an arterial ischemic event was associated with an increased risk of death (hazard ratio [HR], 1.8; 95% confidence interval [CI], 1.6-1.9). In secondary analyses, the mortality risk was elevated after an ischemic stroke (HR, 1.7; 95% CI, 1.5-1.8), and MI (HR, 3.0; 95% CI, 2.4-3.8). We found that elderly patients who survived an ICH had an increased risk of death after a subsequent ischemic stroke or MI.

SCORPION STING CAUSING MULTIPLE WATERSHED INFARCTS

Scorpion sting presents with several neurotoxic local effects, cranial nerve effects (roving eye movements, blurring of vision, tongue fasiculations, dysphagia), central nervous system effects (encephalopathy, convulsions, CVA, central respiratory failure). We report a case of a 53 year old female who sustained a scorpion sting at her residence and initially presented with local site symptoms only. During the course of hospital stay, after 2 days she had a episode of hypotension followed by an episode of generalised tonic clonic seizures and right hemiplegia. MRI brain was suggestive of bilateral acute ischemic watershed infarcts, carotid Doppler was suggestive of low ow bilaterally. Patient was started on dual antiplatelets, anti edema and anti epileptic measures. The patient recovered spontaneously over a period of 2 weeks.

Cytotoxic lesions of the corpus callosum in children: Etiology, clinical and radiological features, and prognosis

ObjectivesCytotoxic lesions of the corpus callosum (CLOCCs) are secondary lesions associated with entities like infection manifested by restricted diffusion on diffusion-weighted cranial magnetic resonance imaging. Our objectives are to evaluate the clinic-radiological spectrum of pediatric patients with cytotoxic lesions of the corpus callosum (CC). MethodsChildren (0–18 years) admitted between February 2017 and May 2020 with splenial lesions showing diffusion restriction on MRI, either isolated or within involvement of other parts of the brain, were included retrospectively. The primary lesions of the CC (e.g. acute disseminated encephalomyelitis, acute ischemic infarction, and glioblastoma multiforme) were excluded. CLOCCs were divided into infection-associated, metabolic disorder–associated, and trauma-associated lesions, as well as CLOCCs involving other entities. Data were collected from the medical databases. ResultsForty-one patients were determined to have CLOCCs. Twenty-five (61%) were infection-associated, nine (22%) were trauma-associated, and three (7%) were metabolic disorder–associated cases, including 2 inherited disorders of metabolism. There were four (10%) patients with other entities, three with epilepsy, and one had an apparent life-threatening event. Six patients had a known etiology among the infection-associated group; one had multisystem inflammatory syndrome caused by COVID-19 and one had been infected by COVID-19 without any complications. All the infection-associated patients with isolated splenial lesions recovered totally, although six patients required intensive care hospitalization. Four trauma-associated patients had sequela lesions. ConclusionsCLOCCs are associated with a spectrum of diseases, including the new coronavirus, COVID-19 infection. Infection-associated CLOCCs has the best prognosis, although severe cases may occur. Sequelae are possible based on the etiology.

Cardio-Cerebral Infarction, Free-Floating Thrombosis and Hyperperfusion in COVID-19

Cardio-cerebral infarction, which refers to an acute ischemic stroke (AIS) and acute myocardial infarction (AMI) that occur concurrently, is an uncommon phenomenon with a grave prognosis. Intraluminal carotid thrombus (ICT) is an infrequently encountered cause of ischemic stroke and can be associated with an underlying hypercoagulable state. One severe yet prevalent complication of infection with Coronavirus Disease 2019 (COVID-19) is thrombosis from multi-pathway inflammatory responses. Here, we present a unique case of cardio-cerebral infarction, with a free-floating intraluminal thrombus in the left internal carotid artery, in the setting of recent COVID-19 infection, and with the etiology of both events attributed to a COVID-19 hypercoagulable state. CT perfusion imaging also showed an interesting imaging finding of hyperperfusion, which is believed to be a form of dysfunctional cerebral autoregulation.

Simultaneous cardio-cerebral infarction: a meta-analysis.

Cardio-cerebral infarction (CCI), which involves the simultaneous occurrence of acute ischaemic stroke and acute myocardial infarction, has a reported incidence of 0.0009%. Treatment of CCI presents a dilemma to physicians as both conditions are time critical. Despite the need for standardized treatment protocols, published data are sparse. We aimed to summarize the reported cardio-cerebral infarction cases in the literature. Meta-analysis. Four databases, Pubmed, Embase, Scopus and Google Scholar were searched until 25 August 2020. A title and abstract sieve, full-text review and extraction of data were conducted independently by three authors. A total of 44 cases of CCI were identified from 37 case reports and series; 15 patients (34.1%) were treated using percutaneous coronary intervention (PCI) with stent, 8 patients (18.2%) were treated with a PCI without stent, 10 patients (22.7%) were treated via a cerebral vessel thrombectomy and 8 patients (18.2%) were treated via a thrombectomy of a coronary vessel. For medications, 20 patients (45.5%) were treated with thrombolytics, 10 patients (22.7%) were treated with anticoagulants, 8 patients (18.2%) were treated with antiplatelets and 11 patients (25.0%) were treated with anticoagulants and antiplatelets. Of 44 patients, 10 patients died, and 9 of those were due to cardiac causes. Among the 44 patients, days to death was observed to be a median of 2.0 days (interquartile range (IQR): 1.5, 4.0). The modified Rankin Score was measured in nine patients, with a median score of 2.0 (IQR: 1.0, 2.5) being reported. The condition of CCI has substantial morbidity and mortality, and further studies are needed to examine the optimal diagnostic and treatment strategies of these patients.

Abstract 011: Cardiovascular Risk Prediction Using Machine Learning In A Large Japanese Cohort

Introduction: Screening for cardiovascular diseases (CVD) at middle age entails precise event prediction to orient risk stratification, resource allocation and insurance policy. Machine learning may be useful to characterize CVD risk and predict outcomes by identifying unique markers of incident CVD. We tested the ability of random survival forests (RSF) to identify the most important markers of incident CVD among adults enrolled in a mandatory screening program. Methods: We examined a dataset comprising annual health checkup, medication, and disease outcome data on 154,957 adults over the age of 40, collected by Toshiba between 2011 and 2017. Health checkup data included laboratory measurements of biomarkers, health history, and lifestyle questionnaires. CVD outcomes, classified as any of acute ischemic heart disease, myocardial infarction, angina pectoris and atherosclerotic heart disease, were recorded after initial health checkup using ICD-10 coding. In the absence of CVD outcomes, subjects’ latest available health check visit was used as the censoring date. Data was split into training (70%, n=108,470) and test (30%, n=46,487) sets, with RSF utilized to impute missing covariate data and determine the characteristics most predictive of CVD outcomes based on minimum depth of maximal subtree. Results: Subjects were 65% (100,376 of 154,957) male with a median age of 47 years at baseline. A total of 1,669 events occurred in the group over a median follow-up period of 5 years. The RSF error rate stabilized around 1000 trees; we grew the training forest with 1200. The c-index at 2, 4, and 6 years was 85%, 84%, and 82% respectively; prediction error calculated by Brier score was 16.4% at six years. The most important predictors of CVD outcomes were prior heart disease, history of CV procedures and age. HDL cholesterol, HBA1c levels, and use of anti-hypertensive medications were the next 3 most important predictors. Conclusions: Determination of key variables predictive of cardiac endpoints will help guide individuals, health practitioners and policy makers in identifying higher-risk subjects and implementing early interventions and testing to reduce risk. The RSF method greatly facilitates the development of a predictive algorithm to be used for these purposes.

Role of continuous hypertonic saline in acute ischemic infarcts: a systematic literature review

Role of continuous hypertonic saline in acute ischemic infarcts: a systematic literature review

Where in the Brain do Strokes Occur? A Pilot Study and Call for Data.

Background: Every year, more than 795,000 people in the United States have a stroke, and each year about 140,000 Americans die from strokes. Although there is abundant information on the epidemiology, risk factors, pathophysiology, and many clinical features of strokes, there is a lack of specific numerical quantitation on the neuroanatomical distribution of strokes.Methods: This retrospective study utilized de-identified reports of radiologic imaging to determine the neurovascular anatomical location of acute ischemic cerebral infarcts in a 637-bed regional hospital in a rural area during the one-year interval from October 1, 2018 through September 30, 2019.Results: During the one-year study period, there were 418 acute ischemic strokes, and 54.6% (228/418) were in the territory of a single large vessel. Of the single large vessel strokes, 62.3% (142/228) were in a middle cerebral artery (MCA) territory, 12.1% (29/228) in a posterior cerebral artery (PCA) territory, 8.8% (20/228) in a basilar artery distribution, 7.5% (17/228) in a posterior inferior cerebellar artery (PICA) distribution, 6.6% (15/228) in an anterior cerebral artery (ACA) distribution, 1.8% (4/228) in a superior cerebellar artery (SCA) distribution, and 0.4% (1/228) in an anterior inferior cerebellar artery (AICA) territory. Internal capsule lacunar strokes accounted for 17.7% (74/418) of the total, brainstem lacunar strokes for 8.1% (34/418) and thalamic lacunar strokes for 5% (21/418) of the infarctions. Watershed infarctions accounted for 2.9% (12/418) of the strokes, 9 in the MCA/PCA watershed area and 3 in the MCA/ACA watershed area.Conclusions: This pilot study illustrates a methodology for collecting data to substitute specific numerical quantitation for vague generalities about the neuroanatomical distribution of strokes. Such quantification can enable evidence-based data-driven improvements in the care of stroke patients.

Dorsal vagal nucleus involvement relates to QTc-prolongation after acute medullary infarction.

Infarction of the medulla has been associated with prolongation of the QTc, severe arrhythmia, and sudden cardiac death, yet the precise anatomical substrate remains uncertain. We sought to determine the possible anatomical structures relating to QTc-prolongation in patients with acute medullary infarction. We included 12 subjects with acute ischemic medullary infarction on brain MRI, who presented within 4.5h from the last known well time, with a 90-day follow-up. For an unbiased lesion analysis, medullary infarcts were manually outlined on diffusion weighted MRI and co-registered with an anatomical atlas. Nine out of 12 had QTc-prolongation. Qualitative and semi-quantitative comparisons were made between infarct location and QTc-prolongation. Among patients with QTc-prolongation, the greatest degree of congruence of the infarct location was over the dorsal vagal nucleus (DVN, 8 out of 9). There was a significant correlation between the number of sections showing infarction of the DVN and presence of QTc-prolongation (r=.582, p=.047). Among patients without QTc-prolongation, the maximum lesion overlap included the medial aspect of the gigantocelluar reticular nucleus of the reticular formation. We found that the DVN is a key anatomical substrate related to QTc-prolongation. Further studies with more patients and high-resolution, volumetric MRI are needed to confirm our findings.

Cardiocerebral Infarction: A Single Institutional Series

ObjectivesCardiocerebral infarction (CCI) is the rare occurrence of acute ischemic stroke (AIS) and acute myocardial infarction (AMI), either at the same time (simultaneous or synchronous) or one after the other (metachronous). The aim of this study is to describe the clinical profile, management and treatment outcomes of patients with CCI. Materials and methodsThis is a 3-year cross-sectional study of patients with CCI describing their clinical presentation, management, and outcomes. The primary outcome measures were all-cause mortality and functional outcome measured with the modified Rankin Scale score (mRS) at discharge and at 30 days post-CCI. We also described the frequency of major and minor hemorrhagic events. ResultsOut of 1683 AIS patients and 1983 AMI patients admitted during our time period, 29 patients fulfilled the inclusion criteria (mean age 60 ±12, 79% males, median admission NIHSS 16 [range 1–26]). Of these, 20 (69%) had metachronous CCI while 9 (31%) had synchronous CCI. Most of the patients were given antithrombotics and only 14% were given reperfusion therapies. The all-cause mortality is 45% and 69% of which were cardiovascular deaths. Seventeen and 21% of CCI patients had a good functional outcome on discharge and at 30 days from CCI onset respectively. A total of 8 (28%) patients had hemorrhagic events. ConclusionsWe present the largest single institutional series showing the prevalence rate of cardiocerebral infarction to be 0.79% (0.55% for metachronous, 0.25% for synchronous), with patients presenting as moderate-severe acute ischemic strokes and high-risk acute myocardial infarction. These patients have a high mortality rate with a significant proportion having cardiovascular deaths.

Hypercoagulability as Measured by Thrombelastography May Be Associated with the Size of Acute Ischemic Infarct-A Pilot Study.

Background: Thromboelastography (TEG®) measures coagulation function in venous blood. Previous studies have reported that this device providing an integrated data on dynamics of clot formation may be useful for predicting clinical outcome in ischemic stroke. We investigated whether a hypercoagulability detected by thrombelastography may be associated with larger size of acute ischemic infarct. Methods: We included 40 ischemic stroke subjects with large artery atherosclerosis or small-vessel disease to a cross-sectional pilot study. Thrombelastography parameters related to time of clot formation (R- reaction time, K-clot kinetics), clot growth and strengthening (angle-alpha and MA-maximum amplitude) and lysis (Ly30) were performed within first 24 h after the onset of stroke. A volume of ischemic infarct was assessed on the basis of diffusion-weighted imaging (DWI) sequence of magnetic resonance imaging. Results: In the entire group, we reported that subjects with a large ischemic focus (>2 cm3) had a higher diameter of a clot (measured as MA) than subjects with a small ischemic focus (p = 0.0168). In the large artery atherosclerosis subgroup, we showed a significant correlation between MA and size of acute infarct (R = 0.64, p = 0.0138), between angle (alpha) and size of acute infarct (R = 0.55, p = 0.0428) and stroke subjects with hypercoagulability (MA > 69 mm) had significantly higher probability of a larger size of acute ischemic focus compared to normalcoagulable subjects (5.45 cm3 vs. 1.35 cm3; p = 0.0298). In multivariate logistic regression hypercoagulability was a predictor of a large size of ischemic infarct (Odds ratio OR = 59.5; 95% confidence interval (CI) 1.08–3558.8; p = 0.0488). Conclusions: We emphasized that thrombelastography, based on the parameters related to clot strength, may have clinical utility to identify the risk of the extensive ischemic infarct.

Decompressive hemicraniectomy for acute ischemic stroke associated with coronavirus disease 2019 infection: Case report and systematic review

Background: Decompressive hemicraniectomy (DH) has been performed for some cases of acute ischemic stroke in patients with coronavirus disease 2019 (COVID-19) infection, but there is little information about the clinical course and outcomes of these patients.Case Description: We report a case of a 36-year-old woman with COVID-19 infection who developed stroke like symptoms while under home quarantine. Cranial CT scan showed an acute left internal carotid artery (ICA) infarct. She subsequently underwent an emergent left DH. Despite timely surgical intervention, she succumbed to chronic respiratory failure. A systematic review of SCOPUS and PubMed databases for case reports and case series of patients with COVID-19 infection who similarly underwent a DH for an acute ischemic infarct was performed. There were eight other reported cases in the literature. The patients’ age ranged from 33 to 70 years (mean 48), with a female predilection (2:1). Respiratory preceded neurologic symptoms in 83% of cases. The ICA was the one most commonly involved in the stroke, and the mean NIHSS score was 20. DH was performed at a mean of 1.8 days post-ictus. Only four out of the nine patients were reported alive at the time of writing. The most common cause of death was respiratory failure (60%).Conclusion: Clinicians have to be cognizant of the neurovascular complications that may occur during the course of a patient with COVID-19. DH for acute ischemic stroke associated with the said infection was reported in nine patients, but the outcomes were generally poor despite early surgical intervention.

Brain and Lung Imaging Correlation in Patients with COVID-19: Could the Severity of Lung Disease Reflect the Prevalence of Acute Abnormalities on Neuroimaging? A Global Multicenter Observational Study.

Our aim was to study the association between abnormal findings on chest and brain imaging in patients with coronavirus disease 2019 (COVID-19) and neurologic symptoms. In this retrospective, international multicenter study, we reviewed the electronic medical records and imaging of hospitalized patients with COVID-19 from March 3, 2020, to June 25, 2020. Our inclusion criteria were patients diagnosed with Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) infection with acute neurologic manifestations and available chest CT and brain imaging. The 5 lobes of the lungs were individually scored on a scale of 0-5 (0 corresponded to no involvement and 5 corresponded to >75% involvement). A CT lung severity score was determined as the sum of lung involvement, ranging from 0 (no involvement) to 25 (maximum involvement). A total of 135 patients met the inclusion criteria with 132 brain CT, 36 brain MR imaging, 7 MRA of the head and neck, and 135 chest CT studies. Compared with 86 (64%) patients without acute abnormal findings on neuroimaging, 49 (36%) patients with these findings had a significantly higher mean CT lung severity score (9.9 versus 5.8, P < .001). These patients were more likely to present with ischemic stroke (40 [82%] versus 11 [13%], P < .0001) and were more likely to have either ground-glass opacities or consolidation (46 [94%] versus 73 [84%], P = .01) in the lungs. A threshold of the CT lung severity score of >8 was found to be 74% sensitive and 65% specific for acute abnormal findings on neuroimaging. The neuroimaging hallmarks of these patients were acute ischemic infarct (28%), intracranial hemorrhage (10%) including microhemorrhages (19%), and leukoencephalopathy with and/or without restricted diffusion (11%). The predominant CT chest findings were peripheral ground-glass opacities with or without consolidation. The CT lung disease severity score may be predictive of acute abnormalities on neuroimaging in patients with COVID-19 with neurologic manifestations. This can be used as a predictive tool in patient management to improve clinical outcome.