Cardiogenic Embolism Research Articles

Mechanical thrombectomy using Solitaire AB stent for acute middle cerebral artery occlusion with atrial fibrillation

To investigate the endovascular management strategy of mechanical thrombectomy using Solitaire AB stent for acute middle cerebral artery occlusion with atrial fibrillation and assess the safety and efficacy. From June 2012 to Dec 2013, 40 patients of acute middle cerebral artery occlusion with atrial fibrillation admitted to our institutes were treated by Solitaire AB stent.Clinical status was evaluated by the score of National Institute of Health Stroke Scale (NIHSS) before and 72 hours after treatment, immediate scale of thrombolysis in cerebral infarction (TICI) after thrombectomy, the 90 d score of Modified Rankin Scale (mRS).The patients were classified into good result group (mRS≤2) and bad result group (mRS>2) according to the mRS score. Out of 40 cases, there were 28 cases caused by cardiogenic embolism. Recanalization was successful (TICI score 2b or 3) in 37 out of 40 (92.5%). 90 d follow-up mRS was 0-2 in 19 of 40 patients (47.5%). 3-5 in 21 patients (52.5%). 5 patients died (12.5%).Symptomatic hemorrhagic transform developed in 6 patients (15%).No complications related to the Solitaire AB thrombectomy occurred.Mean time from symptom onset to recanalization (312±52 min vs 370±68 min, P<0.05) and initial NIHSS score (17.0±0.4 vs 18.6±0.4, P<0.05) were of significant difference between good result group and bad result group. These results confirm that mechanical thrombectomy using solitaire AB stent for acute middle cerebral artery occlusion with atrial fibrillation is safe and effective.

Right-side propensity of cardiogenic emboli in acute ischemic stroke with atrial fibrillation

Right-side propensity of cardiogenic emboli in acute ischemic stroke with atrial fibrillation

Types and risk factors of recurrent ischemic stroke after initial brainstem infarction

To retrospectively analyze the clinical data of 176 patients of recurrent cerebral infarction at our hospital. Based upon the treatment of acute stroke trial (TOAST) classification, the types of recurrent ischemic stroke with initial brainstem infarction were classified. And univariate and multivariate logistic analyses of risk factors were performed. The major types in a decreasing order were atherosclerotic cerebral infarction (AT, n=24, 70.6%), small arterial occlusive stroke (SA, n=8, 23.5%) and cardiogenic cerebral embolism (CE, n=2, 5.9%). Brainstem infarction was more likely to be affected by poor life habits and a history of diabetes mellitus (DM). And atrial fibrillation was a major independent risk factor for non-brainstem infarction. Multivariate logistic analysis showed that poor living habits (P=0.03), a history of DM (P=0.004), vulnerable plaque (P=0.01) and poor compliance of secondary prevention medication (P=0.02) were independent risk factors for recurrent ischemic stroke with initial brainstem infarction. Health education should be strengthened for preventing recurrent ischemic stroke with brainstem infarction. Key words: Brain infaction, relapsing; Risk factors

Acute Splenic Infarction at an Academic General Hospital Over 10 Years: Presentation, Etiology, and Outcome.

Few case series provide a current, comprehensive, and detailed description of splenic infarction (SI), an uncommon condition.Retrospective chart review complemented by imaging evaluation and patient follow-up.All adult patients with a confirmed diagnosis of acute SI discharged over 10 years from a single academic center were studied. A systematic literature review was done to compile a complete list of SI etiologies.SI was found in 32 patients, 0.016% of admissions. Ages ranged from 18 to 86 (median 64) years. Cardiogenic emboli were the predominant etiology (20/32, 62.5%) and atrial fibrillation was frequent. Other patients had autoimmune disease (12.5%), associated infection (12.5%), or hematological malignancy (6%). Nine of the patients (28%) had been previously healthy or with no recognized morbidity predisposing to SI. In 5 of 9 hitherto silent antiphospholipid syndrome or mitral valve disease had been identified. Two remained cryptogenic. Most patients presented with abdominal pain (84%), often felt in the left upper quadrant or epigastrium. Associated symptoms, leukocytosis or increased serum lactate dehydrogenase occurred inconsistently (∼25% each). Chest X-ray showed suggestive Lt. supra-diaphragmatic findings in 22%. Thus, the typical predisposing factors and/or clinical presentation should suggest SI to the clinician and be followed by early imaging by computed tomography (CT), highly useful also in atypical presentations. Complications were rare and patients were discharged after 6.5 days (median) on anticoagulant treatment. The systematic literature review revealed an extensive list of conditions underlying SI. In some, SI may be the first and presenting manifestation.SI is a rare event but should be considered in predisposed patients or those with any combination of suggestive clinical features, especially abdominal pain CT evaluation is diagnostic and the outcome is good.

Emergent cervical surgical embolectomy for extracranial internal carotid artery occlusion.

Acute extracranial internal carotid artery (ICA) occlusion by a huge cardiogenic embolus is rare, but can be catastrophic. Seven patients with acute ischemic stroke due to embolic occlusion of extracranial ICA who underwent emergent cervical surgical embolectomy were retrospectively reviewed. Diagnosis was made in six patients with magnetic resonance imaging (MRI) with optional digital subtraction angiography (DSA), while computed tomography (CT) and DSA were used in one patient with an implanted pacemaker. Clinical outcomes, including recanalization rate, recanalization time, complications, modified Rankin scale (mRS) at 3 months, and National Institute of Health Stroke Scale (NIHSS) score improvement at 1 month were evaluated. Complete recanalization was obtained in seven patients (100 %). Median recanalization time from symptom onset and from start of surgery was 402 and 40 min, respectively. All seven patients showed severe left ventricular hypertrophy (LVH) according to an increased cardiothoracic ratio (CTR) ≥50 %. Complications included recurrence of cardioembolic stroke with the right middle cerebral artery occlusion, minimal expansion of infarction, and aggravation of heart failure, each in one patient, respectively. Four (57.1 %) patients had a history or postoperative recurrence of cardioembolic stroke. Median NIHSS at 1 month was 2 (range, 0-30). Median mRS at 3 months was 2 (range, 0-5). Five patients (71.4 %) had a favorable outcome (mRS2). Cervical surgical embolectomy for acute extracranial ICA occlusion resulted in a high complete recanalization rate with an acceptable safety profile. A possible association between severe cardiac illness and huge embolus occluding proximal large artery was suggested.

Complex interventional treatment in a patient with atrial fibrillation and stroke caused by large carotid artery thrombus: a case report

BackgroundThe treatment option for acute ischaemic stroke depends on the duration of symptoms, the dynamics of neurological condition changes, the aetiology, type of stroke, as well as the results of angiographic and neuroimaging tests.Case presentationA 60-year-old male patient presented with progressive left hemisphere stroke caused by extensive cardiogenic embolism of the common carotid artery and a thrombus closing the internal carotid artery from its ostium to the level of its intracranial division. The complex revascularisation therapy involving surgical embolectomy of the common carotid artery, thrombectomy of the internal carotid artery and intra-arterial thrombolysis has led to the improvement of arterial patency and has countered the progression of acute cerebral ischaemia.ConclusionEmergency carotid embolectomy together with thrombectomy and local thrombolytic rt-PA treatment may be a reasonable rescue therapy for carefully selected patients with large-vessel acute stroke. Further research is needed to establish the advantages and safety of surgical thrombectomy in patients with acute embolic occlusion of the carotid artery and ineffectiveness of or contraindications for systemic thrombolytic treatment.

Is serum total bilirubin useful to differentiate cardioembolic stroke from other stroke subtypes?

Background:Previous studies have reported that the total bilirubin (TB) level is associated with coronary artery disease, heart failure and atrial fibrillation. These heart diseases can produce cardiogenic cerebral embolism and cause cardioembolic stroke. However, whether the serum TB could be a biomarker to differentiate cardioembolic stroke from other stroke subtypes is unclear.Methods:Our study consisted of 628 consecutive patients with ischaemic stroke. Various clinical and laboratory variables of the patients were analysed according to serum TB quartiles and stroke subtypes.Results:The higher TB quartile group was associated with atrial fibrillation, larger left atrium diameter, lower left ventricular fractional shortening and cardioembolic stroke (P < 0.001, P = 0.001, P = 0.033, P < 0.001, respectively). Furthermore, serum TB was a statistically significant independent predictor of cardioembolic stroke in a multivariable setting (Continuous, per unit increase OR = 1.091, 95%CI: 1.023–1.164, P = 0.008).Conclusions:Serum TB level was independently associated with cardioembolic stroke. The combination of clinical data and serum TB may be a feasible strategy to diagnose cardioembolic stroke in the acute phase.

The Presentation of Respiratory Failure in Elderly Individuals

Respiratory failure (RF) is a prevalent condition whose presence in elderly patients may be complex and require specific and specialized intervention. A multidimensional evaluation is necessary to choose the best treatment, taking into consideration functional capacity and frailty. Cardiogenic pulmonary edema, community-acquired pneumonia, pulmonary embolism, bronchitis, and acute asthma are the main causes of RF in this patient population. Despite the limited availability of studies and data, including systematic reviews, regarding RF treatment in elderly patients, in this update, we synthesize data to guide diagnosis, treatment, and health care decision making.

Non-Vitamin K Antagonist Oral Anticoagulants Do Not Increase Cerebral Microbleeds

Atrial fibrillation (AF) is a cardiac arrhythmia that frequently induces ischemic strokes. Nowadays, non-vitamin K antagonist oral anticoagulants (NOACs) have come into widespread use for cardiogenic embolism prevention in place of warfarin. Recently, cerebral microbleeds (CMBs) have been noticed for their potential implication in cerebral small vessel disease. We hypothesized that NOACs do not have an unfavorable influence over cerebral small vessels and investigated whether NOACs increase CMBs in AF patients in a prospective manner. We performed baseline magnetic resonance imaging (MRI) examinations on the 69 enrolled AF patients and re-examined second round of MRI 1 year later. The enrolled patients continued the same anticoagulation therapy during the meantime. CMBs did not develop in the 23 patients with NOACs for 1 year. Nine patients with antiplatelets also did not develop CMBs. On the other hand, 3 of 21 patients continued on warfarin and 3 of 9 with warfarin and antiplatelets had CMBs. When divided into 2 groups according to whether the CMBs developed, significant differences in the incidence of using NOACs were observed between the 2 groups (P=.02). A multivariate regression analysis showed that warfarin was independently related to the new development of CMBs (hazard ratio, 10.75; 95% confidence interval, 1.22-94.99; P=.03). This is the first report to clarify that NOACs do not increase CMBs in AF patients longitudinally in 1 year. Further consideration will be continued with a much longer follow-up in large samples.

Multiple extra-ischemic hemorrhages following intravenous thrombolysis in a patient with Trousseau syndrome: case study.

BackgroundIntracerebral hemorrhage is the most feared complication of intravenous thrombolysis for acute ischemic stroke. Such hemorrhage usually occurs within or at the margin of ischemic or manifestly infarcted brain tissue. A patient with Trousseau syndrome who developed multiple extra-ischemic hemorrhages following intravenous thrombolysis is described.Case descriptionAn 80-year-old Japanese man with no other underlying disease was diagnosed with unresectable advanced lung cancer (stage IV) without brain metastasis and had not yet been treated. The patient suddenly presented with disturbance of consciousness, right hemiplegia, and total aphasia, and was admitted to our hospital. Magnetic resonance imaging revealed acute cerebral infarction extending from the basal ganglia to the corona radiata of the left cerebrum and multiple small areas of bilateral cerebral cortices. Cardiogenic cerebral embolism was considered among the differential diagnoses, but the brain natriuretic peptide level was within the normal range, and no arrhythmias such as atrial fibrillation were observed. With no other causes, the patient was diagnosed with Trousseau syndrome due to hypercoagulability associated with the advanced lung cancer. The patient received intravenous tissue plasminogen activator (t-PA) at 96 minutes after onset of symptoms. His symptoms partially improved, but they suddenly deteriorated at 84 minutes after the thrombolysis. A computed tomography (CT) scan immediately after the neurological deterioration revealed a subcortical hemorrhage in the left occipital lobe. A repeat CT scan the day after onset showed enlargement of the left occipital hemorrhage and two new subcortical hemorrhages in the right frontal and right temporal lobes. These hemorrhages were located in areas remote from the acute ischemic lesions.ConclusionTo the best of our knowledge, this is the first reported case of multiple extra-ischemic hemorrhages following intravenous thrombolysis in a patient with Trousseau syndrome. The course of this case suggests that intravenous t-PA administration for acute ischemic stroke with Trousseau syndrome may be associated with a higher risk of intracranial hemorrhage.

Early administration of therapeutic anticoagulation following intravenous thrombolysis for acute cardiogenic embolic stroke caused by left ventricular thrombus: case report and topic review.

Cardiogenic cerebral embolism represents 20% of all acute ischemic strokes (AISs) with one-third of these being caused by left ventricular thrombus (LVT). LVT is not a contraindication for treatment with intravenous recombinant tissue plasminogen activator (IV rtPA) for AIS. However, the subsequent treatment of a potentially unstable LVT is contraindicated for 24 h following the use of IV rtPA according to current guidelines. We present a 66-year-old man with AIS treated with IV rtPA. Echocardiogram shortly after treatment demonstrated both a large apical and septal thrombus in the left ventricle and at 12 h post IV rtPA infusion, therapeutic anticoagulation with heparin was started without complication. In practice, the action of IV rtPA outlasts its apparent half-life because of thrombin-binding and the prolonged effects and longer half-life of its product, plasmin; however, the pharmacokinetics do not warrant prolonged avoidance of therapeutic anticoagulation when clinically indicated. Our case demonstrates that anticoagulation for potentially unstable LVT can be safely initiated at 12 h following IV rtPA treatment for AIS.

Abstract T P169: Acute Cardioembolic vs. Large Artery Atherosclerotic Infarction-related Lesion Topography and Right-Left Propensity: A Multi-center Quantitative Magnetic Resonance Imaging Study

Background and Purpose: A recent study showed that cardiogenic emboli might flow more frequently into the right hemisphere, whereas atheromatous aortic arch emboli might flow more frequently into the left hemisphere. We tried to 1) see if cardioembolic (CE) infarct volume would be larger in the right hemisphere than in the left hemisphere, and 2) depict anatomical regions showing CE vs. large artery atherosclerotic (LAA) infarction-related right-left propensity. Methods: In this study on carotid artery territory CE (n = 694) vs. LAA (n = 1162) acute ischemic stroke patients who were enrolled consecutively from 11 nationwide stroke centers, we quantitatively registered diffusion magnetic resonance imaging lesions onto the Montreal Neurologic Institute brain template. Results: In patients with bilateral CE stroke (n = 163), right hemispheric infarct size was about two times bigger than the contralateral left hemispheric infarct size (p = 0.002). However, in patients with either unilateral (n = 925) or bilateral (n = 184) LAA stroke, there was no significant difference in the right vs. left hemispheric infarct size between the right vs. left unilateral infarct groups or within the bilateral infarct group (all p &gt; 0.05). In patients with unilateral CE stroke (n = 510), there was no significant difference in the infarct size between the groups with right vs. left hemispheric lesions. Age and infarct volume-adjusted p-value maps of the CE vs. LAA stroke patients, which were corrected for multiple comparisons, revealed the brain regions with a significantly higher infarct frequency in CE stroke than in LAA stroke. The significant clusters were observed only in the right hemisphere, encompassing both the superior and inferior division middle cerebral artery territories, particularly in the pial and corticosubcortical regions including the claustrum and insula. Conclusion: The present multi-center quantitative magnetic resonance imaging study confirms the ‘right &gt; left’ propensity of CE (vs. LAA) stroke.

Abstract W P171: Findings of Magnetic Resonance Imaging and Carotid Duplex as Predictors of Recurrent Brain Infarction -Bingo Cerebral Infarction Study 1-

Introduction: To retrospectively evaluate whether findings of magnetic resonance imaging (MRI) and carotid duplex are predictors of recurrent cerebral infarction. Methods: Between 2007 and 2010, 1324 patients underwent carotid duplex, magnetic resonance angiography, fluid-attenuated inversion recovery imaging, and T2*-weighted imaging during first admission for cerebral infarction and were discharged with a modified Rankin Scale (mRS) score of 0-3. Of the 1324 patients, 1138 (86.0%) were followed up (median age, 70 years; male:female ratio, 64%:36%). Atherothrombotic infarction, lacunar infarction, cardiogenic embolism, and other infarctions occurred in 435, 430, 246, and 27 patients, respectively. Results: The median follow-up duration was 44.5 months; 84.4% patients underwent follow-up MRI. New ischemic brain events occurred in 213 patients (18.7%). Transient ischemic attack occurred as the first new ischemic brain event in 44 patients. New asymptomatic cerebral infarction appeared in 100 patients before or without new ischemic brain events. Symptomatic cerebral infarction (SCI) recurred in 172 cases (15.1%), and the median duration between discharge and recurrence was 18.6 months (range, 0.2-69.5 months). Atherothrombotic infarction, lacunar infarction, and cardiogenic embolism recurred in 64, 64, and 42 patients, respectively. At the last follow-up, mRS score was 0-3 in 1029 patients and 27 patients died. Intracranial artery stenosis and micro-bleeding were significant predictors of SCI after lacunar infarction. Pre-admission asymptomatic old cerebral infarction was a significant predictor of SCI after 3 subtypes. Internal carotid artery stenosis &gt;50% on carotid duplex was a significant predictor of SCI after atherothrombotic infarction. Conclusion: Findings of MRI and carotid duplex may be important predictors of recurrent cerebral infarction.

Abstract T P163: Inpatient Stroke Mortality Has Been Declining in Japan: Japanese Stroke Databank

Background and Purpose: Although thrombolytic therapy, novel oral anticoagulants and neuroendovascular therapy became available in this decade, the stroke victims are facing the increasing risk of death including the comorbidity such as pneumonia due to rapid aging in Japan. As a part of the Japan Standard Stroke Registry Study (JSSRS) which is a multi-center registration study of acute stroke cases in Japan, we analyzed the trends in the inpatient stroke mortality in relation to the demographic data and stroke subtypes. Subjects and Methods: The present study was based on 101,160 acute stroke cases including 59,493 men (58.8%) and 41,667 women (41.2%) who were registered to the JSSRS databank between 1999 and 2012. Among them, 72,774 cases (71.9%) were diagnosed as having cerebral infarction (CI), 17,723 cases (17.5%) as intracerebral hemorrhage (ICH), 5,343 (5.3%) as subarachnoid hemorrhage (SAH), and 5,320 cases (5.3%) as transient ischemic attack (TIA). Results: There were 7,651 deceased cases and the overall mortality rate (MR) was 7.6%. The MR was greater in women (9.2%) than in men (6.4%), and greater in those who were 75 years or older (10.2%) than in younger age categories. The MR was greater for SAH (23.5%) and ICH (15.1%) than for CI (5.1%), and greater for cardiogenic embolism (11.7%) than for atherothrombotic infarction (3.8%) and lacunar infarction (0.6%). Among the deceased cases, 53.7% died in the acute stage whereas 26.0% died in the subacute stage and 20.3% died in the chronic stage. 23% of the in-hospital death was due to SAH in women, whereas that was only 9% in men. The overall MR was 9.2 % and the MR was 6.8% for CI and 15.6% for ICH in 2000, whereas the overall MR was 6.3% and the MR was 3.9% for CI and 13.3% for ICH in 2012. The MR for SAH was 21.4% in 2000 and 21.8% in 2012. Conclusions: The greater stroke MR in women was considered to be due to the greater MR for SAH. Our data revealed the stroke MR decreased significantly in last 12 years. This decline can be partly explained by the improved outcome in cerebral infarction in the acute phase.

Inflammatory markers for short-term prognosis of acute cerebral infarction

Objective To investigate the potential of inflammatory markers for short-term prognosis of acute cerebral infarction. Methods A total of 272 consecutive patients with acute cerebral infarction were divided into a high hs-CRP group (hs-CRP level >3 mg/L) and a low hs-CRP group (hs-CRP level ≤3 mg/L), and their general information and medical history were collected. The Trial of Org 10172 in Acute Stroke Treatment (TOAST) stroke subtype classification was conducted and scores of the National Institutes of Health Stroke Scale (NIHSS), the Barthel index (BI) and the modified Rankin scale (mRS) were collected after admission. White blood cell count, blood glucose, blood homocysteine (Hcy) and C-reactive protein were measured within 24 hours following admission. Multivariate Logistic regression analysis was performed to identify independent risk factors for short-term prognosis of acute cerebral infarction. Results Between the high hs-CRP group and the low hs-CRP group, there were significant differences in the incidences of atrial fibrillation history, cardiogenic embolism of TOAST, blood homocysteine, blood glucose, white blood cell count, NIHSS, BI and mRS score 1, 7, 14 days after admission (P<0.05 for all). The hs-CRP level (OR=0.876, P<0.001, 95% CI: 0.817-0.917), white blood cell count (OR=1.137, P=0.029, 95% CI: 1.013-1.275), lipid metabolism disorders (OR=2.863, P<0.001, 95% CI: 1.561-5.250), and BI score (OR=1.038, P=0.047, 95% CI: 1.001-1.077) 1 day after stroke were independent risk factors for short-term prognosis of acute cerebral infarction. Conclusions Increased levels of the inflammatory marker hs-CRP and elevated white blood cell count may be independent risk factors for short-term prognosis of acute cerebral infarction. Key words: C-reactive protein; Brain infarction; Prognosis

Ambient Temperature Change Increases in Stroke Onset: Analyses Based on the Japanese Regional Metrological Measurements.

Relationships between various climate factors and stroke have long been a subject of investigation. The present study investigated in a single medical center the effects of periodic temperature changes on the onset of intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), atherothrombotic infarction (AI), lacunar infarction (LI), cardiogenic embolism (CE), and transient ischemic attack (TIA). The subjects were 4,310 patients who had been hospitalized because of hemorrhagic or ischemic stroke from January 2000 through December 2005. Ambient temperature data were collected from the Japan Meteorological Agency Database. The following factors were analyzed: number of stroke onsets per day; mean, maximum, and minimum ambient temperatures; and differences between the mean temperatures on the onset day and the previous week. Relationships between temperature factors and totals based on stroke subtypes were assessed by means of regression analyses with a standard least squares model controlling for specific covariates. The daily admissions for ICH, SAH, AI, LI, and CE increased when the mean temperature on the onset day was 1°C lower than that of the previous week. Decreases in minimum ambient temperature predicted increased numbers of admissions for ICH and for SAH. Conversely, a 1°C increase in maximum ambient temperature significantly affected ICH, AI, and CE admissions. There was no definitive relationship between temperature change and admissions for TIA. Both absolute and comparative changes in ambient temperature are related to increased onsets of hemorrhagic and ischemic stroke in Japan.

心原性か大動脈原性かの脳塞栓症診断に苦慮した1例

心原性か大動脈原性かの脳塞栓症診断に苦慮した1例

Top of Basilar Artery Syndrome.

A 45 years old male presented in Department of Medicine at the Shree Shayaji General Hospital with sudden onset bilateral ptosis, dilatation of the pupil and paresis of extraocular muscles. There were area of restricted diffusion on diffusion weighted images with corresponding low ADC (Apparent Diffusion Coefficient) value in periaqueductal region, oculomotor nucleus and medial thalami suggestive of acute infract. In MR cerebral angiographic image filling defect is seen in the basilar artery suggestive of thrombosis [Table/Fig-1,​,22,​,3].3]. Top of the Basilar Artery Syndrome is also known as a Rostral Brainstem Infarction. It is due to the thromboembolic occlusion of the top of the basilar artery. Risk factors for the thrombosis are hypertension [1], diabetes mellitus [2], obesity [2], hyperhomocystinemia [3], and excessive alcohol intake. It may be secondary to the cardiogenic emboli like mural thrombi in myocardial infarction and atrial fibrillations or valvular thrombi in infective endocarditic and valvular heart disease. Hypercoaguable states like antiphospholipid antibodies [4], protein C deficiency [4], protein S deficiency [4] may also leads to the thrombotic events. Small vessel vaculities in sickle cell disease may be associated with it. Bilateral tha lamic ischemia occurs due to occlusion of perforator vessels. Clinically patient develops symptoms like visual and oculomotor deficits and behavioral abnormalities. However, motor dysfunction is often absent [5]. CT angiography, MR angiography and catheter angiographic are the imaging modality use to confirm the finding and demonstrate a filling defect [6]. Prognosis in patient with bilateral ocular palsy is poor. [Table/Fig-1a,b]: Axial section of diffusion weighted MR image shows (A) area of restricted diffusion in oculomotor nuclei region in midbrain (open white arrow) (B) area of restricted diffusion in bilateral medial thalami (open white arrow) [Table/Fig-2a,b]: Axial section of Apparent Diffusion map shows (A) corresponding low ADC value in oculomotor nuclei region in medulla (black solid arrow) (B) in bilateral medial thalami (solid white arrow) [Table/Fig-3a,b]: MR angiographic images shows filling defect in the basilar artery suggestive of thrombosis Top of the basilar artery syndrome is occurring due to thrombotic occlusion of the basilar artery. Patient presented with visual and oculomotor deficit and behaviour abnormalities. MR angiography demonstrate filling defect in the basilar artery.

Cardiac myxoma: An uncommon cause of recurrent stroke in uncommon age

Atrial fibrillation is the most common cause of cardiogenic emboli in stroke, responsible for over 50% cases of total stroke patients. Myxoma is responsible only in few cases. A stroke caused by left atrial myxoma commonly occur in young females. This patient presented with the repeated attack of stroke in the age of 80 years. However, it is the most common benign cardiac tumor found more frequently. In young adults with stroke or transient ischemic attack than in older patients. Age of the patient and unusual cause of recurrent stroke make this case report interesting. An 80-year-old male with no other conventional vascular risk factors such as hypertension, diabetes, or hyperlipidemia presented with left hemiparesis. Infarction over the right middle cerebral artery was disclosed on a magnetic resonance imaging study. The patient was a known case of right hemiparesis 3 years back, which was improved. The cause of repeated attack of stroke was left atrial myxoma, diagnosed by two-dimensional echocardiography.

Integrated Use of Bedside Lung Ultrasound and Echocardiography in Acute Respiratory Failure: A Prospective Observational Study in ICU

BACKGROUND:It has been suggested that the complementary use of echocardiography could improve the diagnostic accuracy of lung ultrasonography (LUS) in patients with acute respiratory failure (ARF). Nevertheless, the additional diagnostic value of echocardiographic data when coupled with LUS is still debated in this setting. The aim of the current study was to compare the diagnostic accuracy of LUS and an integrative cardiopulmonary ultrasound approach (thoracic ultrasonography [TUS]) in patients with ARF.METHODS:We prospectively recruited patients consecutively admitted for ARF to the ICU of a university teaching hospital over a 12-month period. Inclusion criteria were age ≥ 18 years and the presence of criteria for severe ARF justifying ICU admission. We compared both LUS and TUS approaches and the final diagnosis determined by a panel of experts using machine learning methods to improve the accuracy of the final diagnostic classifiers.RESULTS:One hundred thirty-six patients were included (age, 68 ± 15 years; sex ratio, 1). A three-dimensional partial least squares and multinomial logistic regression model was developed and subsequently tested in an independent sample of patients. Overall, the diagnostic accuracy of TUS was significantly greater than LUS (P< .05, learning and test sample). Comparisons between receiver operating characteristic curves showed that TUS significantly improves the diagnosis of cardiogenic edema (P< .001, learning and test samples), pneumonia (P< .001, learning and test samples), and pulmonary embolism (P< .001, learning sample).CONCLUSIONS:This study demonstrated for the first time to our knowledge a significantly better performance of TUS than LUS in the diagnosis of ARF. The value of the TUS approach was particularly important to disambiguate cases of hemodynamic pulmonary edema and pneumonia. We suggest that the bedside use of artificial intelligence methods in this setting could pave the way for the development of new clinically relevant integrative diagnostic models.