Cardioembolic Causes Research Articles

Increased plasma levels of N-terminal pro-B-type natriuretic peptide as biomarker for the diagnosis of cardioembolic ischaemic stroke

BackgroundDespite comprehensive study, the aetiology of stroke is not identified in 35% of cases. AimsWe conducted a study to assess the diagnostic capacity of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in the identification of ischaemic stroke of cardioembolic origin. The secondary purpose of the study was to evaluate the prognostic value of NT-proBNP for predicting 90-day all-cause mortality. MethodsWe designed a prospective observational study including patients hospitalised due to stroke between March 2019 and March 2020. Blood samples were collected on admission to the emergency department and serum NT-proBNP levels were determined. Statistical analysis was performed using a bivariate logistic regression model and receiver operating characteristic (ROC) and Kaplan–Meier curves. Statistical significance was established at p<.05. ResultsThe study included 207 patients with first ischaemic stroke. Plasma NT-proBNP levels were significantly higher (p<.001) in the cardioembolic stroke group (2069pg/mL±488.5). ROC curves showed that NT-proBNP>499pg/mL was the optimum value for diagnosing cardioembolic ischaemic stroke (sensitivity, 82%; specificity, 80%). Moreover, plasma NT-proBNP levels>499pg/mL were independently associated with cardioembolic stroke (OR: 9.881; p=.001). Finally, NT-proBNP>1500pg/mL was useful for predicting 90-day mortality (sensitivity, 70%; specificity, 93%). ConclusionsNT-proBNP was independently associated with cardioembolic stroke and should be quantified in blood tests within 24h of stroke onset. High plasma levels (>499pg/mL) may indicate an underlying cardioembolic cause, which should be further studied, while NT-proBNP >1500pg/mL was associated with increased 90-day mortality.

Recidiverende herseninfarcten met een bijzondere en maligne oorzaak

Nonbacterial thrombotic endocarditis: a case report A patient presented to the emergency room with a right-sided headache since the night before and gait problems. Neurological examination showed a left-sided hemianopia and a left-sided sensorimotor hemiparesis. A CT scan of the brain revealed an ischemic stroke. The patient was treated already with dabigatran and clopidogrel because of a previous ischemic stroke. Due to the presence of infarctions in the perfusion territories of both the middle and posterior cerebral artery, further investigation to look for a cardio-embolic cause was performed. The history of a bronchial adenocarcinoma and the absence of infectious symptoms raised the suspicion of nonbacterial thrombotic endocarditis. A transoesophageal echocardiography showed a hypodense structure on the mitral valve, thereby confirming this diagnosis. Despite anticoagulation with low-molecular-weight heparin, the patient died shortly afterwards as a result of a new, severe ischemic stroke.

Left Atrial Appendage Function Assessment by Tissue Doppler Transesophageal Echocardiography in Acute Ischemic Stroke Patients

Background: Strokes due to Cardioembolic causes are the most severe in ischemic stroke subtypes. LAA flow patterns and function could be assessed accurately by TEE. The study aimed to present the importance of Transesophageal echocardiography in the assessment of LAA function and its relation to cardioembolic stroke. Methods: 120 patients were enrolled in the study and were subdivided into 3 subgroups, each group included 40 patients. Group A; patients had a stroke with normal sinus rhythm, Group B; patients had a stroke with atrial fibrillation, and Group C; normal control subjects. The study participants were evaluated by medical history, physical examination, standard 12-leads electrocardiogram, a transesophageal echocardiographic detailed evaluation of the LAA, and brain CT and/or MRI for patients with stroke. Results: both stroke patients with AF and sinus rhythm had significantly higher LAA mean orifice diameter and higher LAA length than control patients, significantly lower mean LAA medial wall tissue Doppler upward and downward motion velocities than control patients and that patients with stroke and AF had significantly lower mean LAA pulsed wave emptying and filling velocities than both patients with stroke and sinus rhythm and control patients. Presence of LAA thrombi, spontaneous echo contrast, and stroke recurrence were higher in stroked AF patients than stroke patients with sinus rhythm. Conclusion: increased LAA orifice diameter, LAA length, and reduced filling and emptying velocities and upward and downward motion velocities of the medial wall of LAA as detected by TEE are associated with stroke and cardio embolization.&#x0D;

Estonian young stroke registry: High burden of risk factors and high prevalence of cardiomebolic and large-artery stroke.

The aim of the present study was to assess the risk factor burden and stroke etiology of young stroke patients in Estonia and to compare the results with similar cohorts from other countries. This study includes ischemic stroke patients aged 18-54years from the prospective Estonian Young Stroke Registry between 2013 and 2020. All patients were managed in a stroke unit following a prespecified detailed protocol. Data on stroke risk factors, etiology, and stroke severity were analyzed. A total of 437 patients (mean age 44.7 ± 8.3years; 62% males) were included in the registry during the 8-year study period. A total of 50.2% of patients had ≥ 3 well-documented risk factors (higher for men: odds ratio (OR) 3.8; 95% cardiac index confidence interval (CI) 1.8-8.3; p < .001) and 6.2% of patients had ≥ 3 less well-documented risk factors. While 42% of patients had undetermined cause of stroke (34% of them cryptogenic), the second most frequent etiologies were large-artery atherosclerosis and cardioembolism (both 19%). 60 percent of cardioembolic strokes were due to high-risk causes. Large-artery atherosclerosis was more prevalent in men (OR 1.8; 95% CI 1-3.3; p = .05) and among older patients (OR 6.2; 95% CI 1.8-21.4; p = .008). The median National Institutes of Health Stroke Scale score on admission was 3 (interquartile ranges 2-6), stroke was more severe in men (p = .05). Our study revealed that young patients with stroke in Estonia have higher burden of well-documented risk factors, higher prevalence of high-risk cardioembolic causes and higher prevalence of large-artery stroke compared to other young stroke cohorts.

Reexamination of the Embolic Stroke of Undetermined Source Concept.

Occult atrial fibrillation (AF) is a leading cause of stroke of unclear cause. The optimal approach to secondary stroke prevention for these patients remains elusive. The term embolic stroke of undetermined source (ESUS) was coined to describe ischemic strokes in which the radiographic features demonstrate territorial infarcts resembling those seen in patients with confirmed sources of embolism but without a clear source of embolism detected. It was assumed that patients with ESUS had a high rate of occult AF and would benefit from treatment with direct oral anticoagulants, which are at least as effective as vitamin K antagonists for secondary stroke prevention in patients with AF, but with a much lower risk of intracerebral hemorrhage. Two recent large randomized trials failed to show superiority of direct oral anticoagulants over aspirin in ESUS patients. These findings prompt a reexamination of the ESUS concept, with the goal of improving specificity for detecting patients with a cardioembolic cause. Based on the negative trial results, there is renewed interest in the role of long-term cardiac monitoring for AF in patients who fit the current ESUS definition, as well as the clinical implication of detecting AF. Ongoing trials are exploring these questions. Current ESUS definitions do not accurately detect the patients who should be prescribed direct oral anticoagulants, potentially because occult AF is less common than expected in these patients and/or anticoagulants may be less beneficial in patients with ESUS but no AF than they are for patients with stroke with established AF. More specific criteria to identify patients who may be at higher risk for occult AF and reduce their risk of subsequent stroke have been developed and are being tested in ongoing clinical trials.

Incidence and type of arrhythmias recorded by one-month continuous ECG monitoring in stroke patients

Abstract Funding Acknowledgements Type of funding sources: None. BACKGROUND The incidence of atrial fibrillation (AF) following stroke has been studied with implantable loop recorders. However, these devices do not record short lasting AF episodes (&amp;lt;30-120 seconds [s]). In addition, the incidence and type of other clinically relevant arrhythmias is poorly understood in this clinical setting. PURPOSE To evaluate the incidence, type and clinical relevance of arrhythmias detected by one-month continuous ECG monitoring in patients after cryptogenic stroke. MATERIAL AND METHODS Consecutive patients (p) with stroke and no previous AF or other cardioembolic or atheroembolic causes were prospectively enrolled in the study. An external wearable 2-lead ECG monitoring system (NUUBO) was used for 30 days (d) in all of them after the acute phase of the stroke. In the absence of documented AF, a parafibrillatory status was defined as &amp;gt;3000 atrial ectopic beats/d or &amp;gt;2 "micro AF" episodes (fibrillatory burst &amp;lt;30 s)/d or ≥1 episode of "micro AF" &amp;gt;14 s. RESULTS 130 p. were included in the study (age 73 ± 12, 57% males, 19% previous stroke, 7% ischemic cardiopathy, CHA2DSVA2Sc pre-stroke 3.1 ± 1.7). 3 were withdrawn from the study due to inadequate use (recording time &amp;lt;14 d) and 1 due to stroke during SARS-CoV2 infection. Total recording time was 28 ± 3 d, total analyzable ECG time was 23 ± 5 d. ECG monitoring was repeated in 12 (9.5%) p due to poor ECG quality in 6 p or high suspicion of AF despite an initial negative result in 6 p. AF &amp;gt;30 s was detected in a total of 27 (21.4%) p, average AF duration was 52 hours (range 30 s-22 d). AF &amp;gt;30s was detected in 2 (17%) p with repeated monitoring. All these patients were placed on anticoagulation. Sustained paroxysmal supraventricular tachycardia (SVT) was documented in 4 (4.4%) p without AF. All episodes of AF and SVT were asymptomatic. Mobitz I second degree AV block in 4 (3.2%) p. 3 (2.4%) p had a pacemaker implanted: 2 for severe sinus dysfunction and 1 for AV block. High-density ventricular ectopy (&amp;gt;3000/d) was present in 7 (6%) p and ≥1 episode of non-sustained ventricular tachycardia was detected in 26 (21%) p. A parafibrillatory status was identified in 27 (21%) p with no AF &amp;gt;30 s. At 1-year follow up 4/22 (18%) of patients with parafibrillatory status and 3/59 (5%) without parafibrillatory status suffered a new stroke (p = 0.08). CONCLUSIONS AF and other potentially relevant arrhythmias are frequent after stroke and easily detectable with one-month non-invasive continuous ECG monitoring. Patients with a parafibrillatory status could benefit from longer monitoring time to detect AF.

Combined Omic Analyzes of Cerebral Thrombi: A New Molecular Approach to Identify Cardioembolic Stroke Origin.

The diagnosis of cardioembolic stroke can be challenging for patient management in secondary stroke prevention, particularly in the case of covert paroxysmal atrial fibrillation. The molecular composition of a cerebral thrombus is related to its origin. Therefore, proteomic and metabolomic analyses of the retrieved thrombotic material should allow the identification of biomarkers or signatures to improve the etiological diagnosis of stroke. In this pilot study, the proteome and metabolome of cerebral thrombi from atherothrombotic and cardioembolic stroke patients were studied according to ASCOD phenotyping (A: atherosclerosis; S: small-vessel disease; C: cardiac pathology; O: other causes; D: dissection), with the highest causality grade, from the ThrombiOMIC cohort (consecutive patients with stroke recanalized by mechanical thrombectomy in an acute phase). Proteomic and metabolomic results were used separately or combined, and the obtained omic signatures were compared with classical cardioembolic stroke predictors using pairwise comparisons of the area under receiver operating characteristics. Among 59 patients of the ThrombiOMIC cohort, 34 patients with stroke showed a cardioembolic phenotype and 7 had an atherothrombotic phenotype. Two thousand four hundred fifty-six proteins and 5019 molecular features of the cerebral thrombi were identified using untargeted proteomic and metabolomic approaches, respectively. Area under receiver operating characteristics to predict the cardioembolic origin of stroke were calculated using the proteomic results (0.945 [95% CI, 0.871–1]), the metabolomic results (0.836 [95% CI, 0.714–0.958]), and combined signatures (0.996 [95% CI, 0.984–1]). The diagnostic performance of the combined signatures was significantly higher than that of classical predictors such as the plasmatic BNP (B-type natriuretic peptide) level (area under receiver operating characteristics, 0.803 [95% CI, 0.629–0.976]). The combined proteomic and metabolomic analyses of retrieved cerebral thrombi is a very promising molecular approach to predict the cardioembolic cause of stroke and to improve secondary stroke prevention strategies.

Update on Biomarkers Associated to Cardioembolic Stroke: A Narrative Review.

Background: In the last years, several studies were conducted that evaluated biomarkers that could be helpful for cardioembolic stroke diagnosis, prognosis, and the determination of risk of stroke recurrence. Methods: We performed a narrative review of the main studies that evaluated biomarkers related to specific cardioembolic causes: atrial fibrillation, patent foramen ovale, atrial cardiomyopathy, and left ventricular wall motion abnormalities. Results: BNP and NT-proBNP are, among all biomarkers of cardioembolic stroke, the ones that have the highest amount of evidence for their use. NT-proBNP is currently used for the selection of patients that will be included in clinical trials that aim to evaluate the use of anticoagulation in patients suspected of having a cardioembolic stroke and for the selection of patients to undergo cardiac monitoring. NT-proBNP has also been incorporated in tools used to predict the risk of stroke recurrence (ABC-stroke score). Conclusions: NT-proBNP and BNP continue to be the biomarkers most widely studied in the context of cardioembolic stroke. The possibility of using other biomarkers in clinical practice is still distant, mainly because of the low methodological quality of the studies in which they were evaluated. Both internal and external validation studies are rarely performed for most biomarkers.

Susceptibility Vessel Sign in Relation With Time From Onset to Magnetic Resonance Imaging.

In acute ischemic stroke, the susceptibility vessel sign (SVS) on T2* MR-sequence witnesses the red blood cell content of the clot. Although clot composition strongly depends on its age in vitro, the relationship between SVS and time has not been studied. In this study, we evaluated whether the presence of SVS was related to the time from symptom onset. We retrospectively analyzed our institutional registry of patients with acute stroke between November 2007 and June 2018. We included patients with an ischemic stroke confirmed by diffusion-weighted imaging magnetic resonance imaging within 8 hours from symptom onset caused by M1 or M2 occlusion and with interpretable T2*-weighted images. We compared clinical and imaging variables among SVS+ and SVS− patients. Time from onset was split into tertiles. Independent markers of SVS+ were identified using multivariable logistic regression. The probability of being SVS+ given time from symptoms onset was modeled using Probit regression. Among the 608 patients included, 433 (71.2%) were SVS+. The odds of being SVS+ increased with time from symptom onset (P trend=0.005). In the multivariable analysis, factors independently associated with a SVS+ were symptom onset to magnetic resonance imaging ([130–180 min] odds ratio [OR], 1.62 [95% CI, 1.03–2.53]; [>180 min] OR, 3.14 [95% CI, 1.92–5.12]), type of magnetic resonance imaging-scanner (OR, 2.83 [95% CI, 1.82–4.41]), cardioembolic cause (OR, 1.51 [95% CI, 1.02–2.24]), and baseline National Institutes of Health Stroke Scale (OR, 1.05 [95% CI, 1.01–1.08]). The probability of being SVS+ increased with time from symptom onset (P=0.004): around 60% at 1 hour, 70% at 3 hours, 80% at 6 hours, and 90% at 8 hours. In acute ischemic stroke, the presence of SVS depends on time from onset to imaging.

Acute Ischemic Stroke in COVID-19 Patient with Lung Collapse: A Case Report

Novel corona virus 2019 also known as severe acute respiratory syndrome coronavirus 2 [SARS COV2] is enveloped non segmented ribonucleic acid (RNA) virus. Acute ischemic stroke remains emergency during covid19 pandemic [1] Here we present a case of a woman with COVID 19 who presented to us with symptoms of altered state of consciousness (ASOC), cough, fever, dysarthria, right sided body weakness and massive bilateral middle cerebral artery (MCA)/ anterior. Our case was unique in the sense that it showed drastic central nervous system (CNS) damage in the presence of coronavirus infection. There are a few cases of patients who develop stroke after COVID 19 infection.&#x0D; Aims: Clinicians need to be aware of possible causes of unconsciousness in coronavirus disease (COVID 19) patients, particularly as delirium appears to be common complications to find out the association between stroke and COVID 19 and its impact and mortality.&#x0D; Case Presentation: A 70 years old lady presented to us with symptoms of stroke like ASOC, right sided body weakness, dysarthria, and symptoms of pneumonia like mild cough and fever later which turned out to be COVID 19. Clinicians need to be aware of possible causes of unconsciousness in coronavirus disease (COVID 19) patients, particularly as delirium appears to be common complications to find out the association between stroke and COVID 19 and its impact and mortality.&#x0D; Discussion: Bilateral ischemic stroke is relatively uncommon presentation in general population and is usually the result of cardio embolic cause such as atrial fibrillation and recent myocardial infarction. While this patient had pre existing risk factors for stroke such as type 2 diabetes mellitus, hypertension and old age and her electrocardiography showed sinus rhythm.&#x0D; Conclusion: COVID-19 may be a risk factor or aggravating factor for stroke.

Thrombectomy for Basilar Artery Occlusion with Mild Symptoms

To evaluate outcomes of thrombectomy in patients with a basilar artery occlusion (BAO) and mild symptoms, defined by an initial National Institutes of Health Stroke Scale (NIHSS) score ≤6. We performed a retrospective analysis of a multicenter prospective cohort of consecutive patients with acute ischemic stroke with BAO who underwent thrombectomy. We compared baseline and procedural characteristics, as well as outcomes between patients with BAO with an NIHSS score ≤6 and >6. Multivariate analyses were performed to determine baseline and procedural predictors of good outcome (modified Rankin Scale score 0-2) among patients with an NIHSS score ≤6. A total of 269 patients were included: 50 (19%) had an initial NIHSS score ≤6 and 219 (81%) had an NIHSS score >6. Patients with mild strokes (NIHSS score ≤6) had better outcomes (68% of modified Rankin Scale score 0-2 vs. 27% for NIHSS score >6; P < 0.0001), lower mortality (14% vs. 48; P < 0.0001) and fewer parenchymal hematomas at day 1 (0% vs. 10%; P= 0.016). A multivariate analysis identified the following predictors for good outcome among patients with BAO with an NIHSS score ≤6: younger age, fewer passes, a cardioembolic cause, and the absence of need for angioplasty/stenting. Thrombectomy seems to be safer and more effective for mild BAO strokes with NIHSS score ≤6 than for more severe patients. Even although thrombectomy showed high rates of recanalization, a substantial proportion (32%) nevertheless had a poor long-term clinical outcome. The number of passes, patient's age, and stroke cause seem to be predictors of clinical outcome.

Comparison of upper extremity versus lower extremity vein injections of bubble contrast in assessment of patent foramen ovale

Abstract Background Patent foramen ovale (PFO) is one of the causes of cardioembolism and closure of PFO is recommended by the current guidelines in patients with recurrent stroke. Transoesophageal echocardiography (TEE) using bubble-contrast study is the gold standard imaging modality for the assessment of interatrial septum. Upper-extremity veins are the most common way of injection, however, the presence of Eustachian valve and flow dynamics when bubble-contrast injection performed via upper extremity veins limits the assessment of interatrial septum in several cases. In this study, we aimed to compare the efficacy of bubble-contrast study between upper extremity injection and lower extremity injection. Material/Methods Patients with a suspicion of cardioembolism who were undergoing TEE study were included in this study. After routine assessment of cardiac structures, the bubble-contrast study was performed using agitated saline from both upper-extremity vein and lower-extremity vein with Valsalva manoeuvre. Right-to-left shunt and numbers of bubbles transmitted from the septum were recorded. Results We prospectively included 45 patients and 21 PFOs were detected. There were 9 patients with prominent Eustachian valve and in 6 patients Eustachian valve hampered the complete opacification of the right atrium. In 3 patients flow from the superior vena cava was directed towards the tricuspid valve and hampered the complete opacification. Among 21 patients with PFO, in 6 patients right-to-left shunt was not observed when agitated-saline was injected via the upper-extremity vein, however, the shunt was observed when the agitated-saline was injected via the lower-extremity vein. In 14 patients amount of bubbles passing through the interatrial septum were significantly higher when the injection was performed via the lower-extremity vein especially in patients with prominent Eustachian valve. Conclusion Our preliminary results indicated that compared to upper-extremity veins, injection via the lower-extremity veins provides better opacification of right atrial septum and assessment of interatrial septum. Therefore, injection through the lower-extremity veins would be the preferred choice particularly in patients with prominent Eustachian valve or downward directed flow from the superior vena cava. Figure 1 Funding Acknowledgement Type of funding source: None

Association Between Thrombus Perviousness Assessed on Computed Tomography and Stroke Cause.

A recent study proposed that thrombus perviousness (TP)-the degree to which contrast agents penetrate the thrombus in an occluded vessel measured on noncontrast computed tomography (NCCT) and CT angiography-may be associated with cardioembolic stroke cause with high specificity. Our aim was to investigate which clinical and laboratory parameters affect measures of TP and to validate its diagnostic accuracy in an independent cohort of patients with acute ischemic stroke. Seventy-five patients from a prospectively maintained database with proximal occlusions of the middle cerebral artery (M1) were retrospectively analyzed. Thrombi were segmented on coregistered noncontrast computed tomography and CT angiography to determine the thrombus attenuation increase and void fraction (attenuation increase relative to contralateral side). TP measures were significantly higher in patients with cardioembolic stroke compared to patients with stroke attributed to large artery atherosclerosis (median thrombus attenuation increase [interquartile range], 2.79 [-3.54 to 8.85] versus -5.11 [-11.23 to -1.47]; P=0.001). In linear regression analysis for TP including age, time to scan, prior medication with antiplatelets or anticoagulants, and selected laboratory parameters, only stroke cause was significantly associated with TP. In multivariable binary logistic regression analysis for dichotomized stroke cause (ie, cardioembolic versus noncardioembolic stroke), only thrombus attenuation increase was independently associated with cardioembolic stroke (odds ratio of 1.12 [95% CI, 1.04-1.22]; P=0.004). Receiver operating characteristic analysis indicated that TP can identify cardioembolic stroke with an area under the curve of 0.75 (95% CI, 0.63-0.87) for thrombus attenuation increase. With a cutoff value of 6.23 Hounsfield units, cardioembolic strokes were identified with 100% specificity. Results for void fraction were similar. The assessment of TP on baseline noncontrast computed tomography/CT angiography in patients with M1 occlusion may aid in determining cardioembolic stroke cause and guide secondary prevention. Selected clinical and laboratory parameters other than stroke cause did not affect TP measures.

Primary Multivessel Occlusions Treated With Mechanical Thrombectomy: A Multicenter Analysis and Systemic Literature Review.

Acute ischemic stroke caused by primary multivessel occlusions (pMVO) is a rare but devastating disease. Whether multi-target mechanical thrombectomy for pMVO is beneficial remains unknown. Multicenter retrospective review of patients treated with multi-target mechanical thrombectomy. The following pMVO sites were included: basilar artery, internal carotid artery, and middle cerebral artery (M1 and M2). Baseline characteristics were reported together with interventional technique, technical efficacy, and safety parameters. Clinical outcomes were evaluated applying the National Institutes of Health Stroke Scale and modified Rankin Scale. A systematic literature review was performed to summarize previous reports on pMVO mechanical thrombectomy. Of 6081 patients screened, 21 patients met the inclusion criteria (0.35% [95% CI, 0.23%-0.53%]). In 70% (14/20) a cardioembolic cause was reported. A successful reperfusion of Thrombolysis in Cerebral Infarction scale score ≥2b was achieved in 95.2% (20/21) for the first and 76.1% (16/21) for the second target vessel. In those who survived the acute hospital stay (n=10/21), median admission National Institutes of Health Stroke Scale improved from 21 (interquartile range, 13-27) to 8 (interquartile range, 2-20) at discharge (P=0.006). Mortality was 60% (12/20) at 90 days and only 20% (4/20) of patients reached modified Rankin Scale score ≤2. Acceptable outcomes were almost exclusively observed in pMVO patients presenting with at least one M2 occlusion. Multi-target mechanical thrombectomy for pMVOs is rarely performed; however, the procedure appears to be feasible and safe with high reperfusion rates for both occlusion sites. More than half of all treated patients deceased early and favorable outcomes may only be expected for pMVO patients including at least one M2 occlusion.

Prevalence and risk factors of ischaemic stroke in the young: a regional Australian perspective.

There is no universally accepted age cut-off for defining young strokes. We aimed to determine, based on the profile of young stroke patients in our regional centre, an appropriate age cut-off for young strokes. A retrospective analysis of all ischaemic stroke patients admitted to our centre from 2015 to 2017. We identified 391 ischaemic stroke patients; 30 patients between the ages of ≤50, 40 between 51-60 inclusive and 321 ≥ 61 years of age. We collected data on demographic profiles, risk factors and stroke classification using the Trial of Org 10 172 in Acute Stroke Treatment criteria. We found significant differences between the ≤50 and ≥61 age groups for most of the risk factors and similarities between the 51-60 inclusive and ≥ 61 age groups. At least one of the six risk factors assessed in the study was present in 86.7% of the youngest group, 97.5% of the intermediate age group and 97.2% in the oldest group. In terms of the mechanisms of stroke, the youngest and oldest age groups in our study differed in the prevalence of cryptogenic, cardioembolic and other causes of stroke. The middle and older age groups had similar mechanisms of stroke. The prevalence of vascular risk factors and mechanisms of stroke likewise differed significantly across age groups. This study suggests that 50 years is an appropriate age cut-off for defining young strokes and reinforces the importance of primary prevention in all age groups.

Stroke in the young’s: about a young woman case

According to epidemiological data, stroke’s incidence is clearly growing, especially in young people under 45. Ischemic stroke is the most common type (80%). Many risk factors have been identified, including hypertension, tobacco, dyslipidemia, diabetes, alcohol, and oestroprogestogenic contraceptive pill. The main mechanisms are atheroma of large arterial trunks, occlusion of small cerebral arteries unrelated to atherosclerosis, and cardio-embolic causes. The aim of our study is to present a clinical case of ischemic stroke in young subjects caused by heart disease at high embolic risk.

Risk factors including prothrombotic work up in young ischemic stroke Indian patients

Background: Stroke in young poses a major health problem. Various Indian studies have shown the incidence of stroke to be 10-15%. Cerebral venous thrombosis and rheumatic heart disease are the leading causes of stroke in the young in India. Thrombophilic factors have been implicated in 4-8% of the young strokes worldwide. Protein C deficiency is the most common thrombophilia marker followed by a deficiency of protein S, Factor V Leiden mutation, and antithrombin (AT) deficiency. Aims and objectives was the study of stroke in young is important for various reasons. The etiology and risk factors are more diverse and different as compared to the elderly. Therefore, these may indicate separate therapeutic approaches. The aim is to study the profile of ischemic stroke cases among the young.Methods: The study was carried out at a tertiary care defence hospital between December 2018 to December 2019. All cases of fresh ischemic stroke who were more than 15 and less than 45 years of age were included. Following clinical evaluation, patients underwent complete haemogram, blood sugar levels, lipid profile and other metabolic parameters. All patients were subjected to chest radiography, 12 lead ECG, and 2D echocardiography, Non-contrast CT head and MRI brain. Prothrombotic work up was also done.Results: A total of 41 patients (12.69%) presented with ischemic stroke before 45 years of age. Out of these 10 (24%) were females and 31 (76%) were male. None of the women smoked or consumed alcohol. Among the males, 19 (47%) smoked more than 10 cigarettes or bidis per day and 9 (22%) were moderate-to-heavy drinkers of alcohol. Hypertension was present in 7 (18%) and diabetes mellitus in 3 (7%) patients. Serum cholesterol was elevated in 7 (18%) patients and triglycerides in 17 (42%). Protein S deficiency was found in 28.8% patients, while protein C deficiency was detected in 21% patients and antithrombin III deficiency in 12% patients.Conclusions: Although traditional risk factors, such as hypertension, diabetes, and smoking, are associated with stroke in both elderly and young, this study shows that other modifiable risk factors such as alcohol consumption were also prevalent. The most common etiological cause was found to be venous infarction followed by cardio embolic cause. Deficiency of Protein S was the most common prothrombotic defect followed by deficiency of Protein C.

Predictive Markers of Atrial Fibrillation in Patients with Transient Ischemic Attack

Background: Atrial fibrillation (AF) is a major cause of cardio-embolism in patients with stroke and transient ischemic attack (TIA). Insertable cardiac monitors (ICM) make long-term monitoring for AF possible, but limited health care resources make patient selection important. AF is associated with atherosclerosis and markers of this could potentially be used to guide AF monitoring. Methods and Results: One-hundred fourteen TIA-patients without AF were thoroughly monitored for AF with ECG, 72-hour Holter monitoring and ICM with a median monitoring time of 2.2 years. Patients with AF (n = 18) were significantly older than patients without AF (age 71.1 versus 64.4 years, P = .008) but were otherwise similar in regards to comorbidities. AF patients had significantly thicker carotid intima-media and also more often presence of carotid plaques than patients without AF, but no difference was found after adjusting for age and sex. No difference in noncontrast cardiac CT calculated coronary artery calcium score was found between the 2 groups. Serum biomarkers did not differ between groups, except for brain natriuretic peptide (BNP), where patients with BNP in the upper tertile were more likely to have AF than patients with BNP in the lowest tertile, odds ratio 5.96 (95% confidence interval 1.04-34.07, P = .045). Conclusions: Carotid intima-media thickness and coronary artery calcium score were poor predictors of AF in patients with TIA. Apart from BNP, the examined biomarkers (hs-CRP, MR-proADM, c-TnI, copeptin) had no predictive value, but larger scale studies are needed to confirm these findings.

P1263 Acute cerebrovascular infarct in a young adult with double septal defect and double outlet ventricle

Abstract Introduction Double outlet right ventricle is a rare cause of acute cerebrovascular disease among young adults. Case. We report a case of a 21 year old male who presented with aphasia and left sided weakness. This was associated with cyanosis, easy fatigablity, recurrent epistaxis and loss of consciousness since childhood. On admission, patient’s vital sign was stable at 100/60, 90 bpm regular, 20 cycles per minute afebrile 80% oxygen saturation on room air. Patient is conscious, aphasic but follows simple commands. He had central cyanosis, clubbing of the upper and lower extremities, adynamic precordium, single s2, right ventricular heave, grade 3/6 systolic ejection murmur at the 2nd left intercoastal space parasternal line, 4/6 holosystolic murmur at the 4th intercoastal space parasternal line, and clear breath sounds. Neurologic examination revealed a 0/5 motor response on both left upper and lower extremity. Cranial MRI showed acute ischemic infarcts at the right frontal centrum semiovale and left cerebral hemisphere. During his admission, cardiac work up was done to investigate cardioembolic cause of the acute cerebrovascular disease. Transesophageal echocardiogram revealed congenital heart disease situs solitus with atrioventricular discordance; double outlet right ventricle, pulmonic valve stenosis, interatrial septal aneurysm with atrial septal defect and persistent left superior vena cava syndrome. During his hospital course, patient was started on aspirin, citicholine and atorvastatin for his cerebrovascular disease which was noted to improve after 2 days. Patient was also referred to the thoracovascular surgery team for comanagement who did modified Blalock Tausig shunting. Patient was referred to cardiac rehabilitation post procedure. His vital signs remained to be stable, his oxygen saturation increased to 90% at room air, and his functional capacity improved. Patient was discharged stable. Discussion Double outlet right ventricle is a rare complex congenital heart disease characterized by a conotruncal malseptation from which more than or equal to 50% of each great artery arises from the morphologic right ventricle. Associated defects like atrial septal defect and persistent left superior vena cava were reported in some literature. Cerebrovascular infarcts in complex cyanotic congenital heart disease might be secondary to polycythemia and/or paradoxical emboli bypassing the interatrial defect. Prompt prophylaxis such as periodic phlebotomy and/or anticoagulation in patients high risk for deep vein thrombosis must be evaluated for each patient.

A practical approach to infarction of the spleen as a rare manifestation of multiple common diseases

Introduction: There are insufficient data on the aetiologic factors underlying splenic infarction (SI). Therefore, there is no consensus regarding the appropriate diagnostic approach.Methods: We conducted a retrospective analysis of all patients admitted with SI from January 2004 to December 2014. Medical records were screened for the clinical presentation, underlying causes, associated medical conditions and methods of patient evaluation.Results: We found 89 subjects with 90 episodes of SI. Presentation of SI was characterized by abdominal, flank and chest pain (82.2%, 18.9%, 7.8%, respectively); leukocytosis (in 67% of tested subjects); elevated LDH (72%), CRP (97.5%) and D-Dimer (100%). The main underlying mechanisms were cardioembolic (54.4%), vascular (20%), haematologic disorders (15.6%) and multiple causes (21.1%). Atrial fibrillation and atherosclerosis were common in older patients (age > 70 years) while antiphospholipid syndrome occurred exclusively in younger individuals. SI was the presentation of previously unknown medical conditions in 38% of patients. Abdominal CT, ECG, echocardiography and blood cultures demonstrated the highest diagnostic yield.Conclusions: Contributing factors are identified in the majority of SI patients. We recommend CT, ECG, echocardiography and blood cultures in all cases. Atrial fibrillation should be sought in older patients, while APLS and haematologic disorders should be suspected in younger ones.KEY MESSAGESThere is no consensus regarding the diagnostic approach and management of splenic infarction.Cardiovascular disease and atrial fibrillation are the main causes for SI in elderly subjects while hematological, infectious and other causes are more prevalent in younger ones.Our data strongly suggests a high diagnostic yield for CT scan, ECG, blood culture and echocardiogram in every patient with SI.