Cerebral Attacks Research Articles

ADC restriction is not associated with clinical response to plasma exchange following a cerebral attack of multiple sclerosis.

MS is the most common CNS inflammatory demyelinating disease. Plasma exchange (PLEX) has well-demonstrated efficacy in acute corticosteroid-refractory attacks of demyelination but identifying the factors that predict favorable PLEX response remains elusive. We aimed to determine if apparent diffusion coefficient (ADC) restriction on brain MRI predicts clinical response to PLEX in individuals with an acute cerebral attack of MS. Retrospective chart review of individuals with a cerebral attack of MS who underwent PLEX at Mayo Clinic. We identified 34 individuals who fulfilled the inclusion criteria.Twenty-seven (79%) responded to plasma exchange, with 16/34 (47%) having moderate and 11/34 (32%) marked improvement. Twenty-three (68%) people had ADC restriction on brain MRI prior to PLEX. ADC restriction did not predict response (p=0.51). Several other pre-PLEX factors, including sex, Expanded Disability Status Scale (EDSS) at initial attack, time to PLEX, and concurrent spinal cord attack, also failed to predict response. Plasma-exchange responders had less disability at 6-month follow-up compared to non-responders (median EDSS 2.5 (range 1.0-10.0) vs. 7.5 (5.5-10.0), p<0.001). Acute cerebral attacks of MS have a high rate of plasma exchange response resulting in a lower EDSS at 6-months. ADC restriction does not predict response to plasma exchange.

Cerebral Attacks in MOG Antibody-Associated Disease: Clinical Spectrum and Fulfillment of ADEM criteria (S40.007)

Cerebral Attacks in MOG Antibody-Associated Disease: Clinical Spectrum and Fulfillment of ADEM criteria (S40.007)

Cognitive sequelae in MOG antibody-associated disease (P13-5.025)

Cognitive sequelae in MOG antibody-associated disease (P13-5.025)

The relationship between thrombotic genetics markers and recurrent arterial ischemic stroke in young (S36.007)

<h3>Objective:</h3> This study aims to determine significant clinical and genetic factors of AIS recurrence. <h3>Background:</h3> The involvement of thrombotic genetic markers such methylenetetrahydrofolate reductase (MTHFR) polymorphisms (C677T and A1298C), factor V Leiden (FVL), G20210A mutation of prothrombin (PT) and recurrent arterial ischemic stroke (AIS) in adults remains unclear. <h3>Design/Methods:</h3> We investigated a cohort study of AIS patients (18–50 years old) followed in the neurology department over 5 years. Traditional and genetic risk factors were carried out through a multivariable logistic regression model. <h3>Results:</h3> Two hundred and seventy patients were enrolled in our study. The risk of AIS recurrence was 36.2% within 5 years. The potential risk of recurrence of AIS increased with traditional risk factors notably hypertension, diabetes mellitus, heart failure, and family history of cerebrovascular diseases. The TT polymorphism of MTHFR 677 increased 2.4-fold the risk of AIS recurrence (OR: 2.47; 95%CI [1.35–4.53]). Both variants AC and CC of MTHFR 1298 polymorphism were associated with a second ischemic cerebral attack (OR:2.68, 95%CI [1.44–4.90], 6.89, 95%CI [2.35–20.23], respectively). The GA variation of FVL was considered a significant genetic factor increasing the risk of AIS recurrence 2.5-fold (OR: 2.54; 95% CI [1.15–5.61]). But, no significant difference was observed between the two groups concerning PT mutation. <h3>Conclusions:</h3> Our findings suggest that besides traditional risk factors, the MTHFR polymorphisms, and FVL play an important role in increasing the risk of recurrent AIS in young patients. <b>Disclosure:</b> Miss M’barek has nothing to disclose. khadija maalla has nothing to disclose. Nadia Bouattour has nothing to disclose. Sawsan Daoud has nothing to disclose. Nouha Farhat has nothing to disclose. mariem damak has nothing to disclose. Salma Sakka has nothing to disclose. Prof. Mhiri has received personal compensation for serving as an employee of Hikma. Prof. Mhiri has received personal compensation for serving as an employee of Sanofi Genzyme. Prof. Mhiri has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Novartis. Prof. Mhiri has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Roche.

Time to adequately heed Acute Pain in the Emergency Department – More Regional Blocks Warranted

All healthcare stressors converge in the emergency department (ED), which sees an annual increase of 6-7% with more than 25 million patient visits in the UK. This translates to 44,435 attendances per 100,000 population in the period 2019-2020 [1]. Acute pain is the primary reason patients seek emergency medical care. Consequently, substandard acute pain treatment is one of the most frequently heard complaints and has been labelled as a public health problem [2]. Pain remains under-acknowledged, -assessed and -treated, mainly in case of overcrowding in the ED and especially in the more vulnerable groups, including the elderly and children. Many patients express an initial pain score of 10 out of 10 on the visual analogue scale (VAS) in the ED. Generally, initial pain treatment combines oral acetaminophen, NSAID and/or (IV) opioids. Nevertheless, despite these pain killers, most patients continue to suffer and score their pain at 8/10 or higher. Untreated pain can have both short- and long-term effects, including sensitisation to pain episodes in later life [3]. Most visits to the emergency department involve patients with conditions that include: a) injuries and trauma from (motor vehicle) accidents, physical assaults or falls, with or without circulatory shock; b) cardiovascular and cerebral attacks or loss of consciousness; c) severe pain of diverse causes, both acute and chronic origin; d) acute worsening of a serious illness or disease, including problems with breathing and bleeding; e) mental illness; f) burns; g) anaphylactic and allergic reactions; g) drug overdoses and poisoning; and h) pregnancy-related complications. In most of these cases, patients present with pain as a substantial factor. Keywords: Emergency department, Hip fracture, Pain, Regional anaesthesia, Nerve blocks, Ultrasonography

Visual texture agnosia caused by bilateral posterior cerebral artery stroke: a case study

ABSTRACT A 57-year-old man presented with a bilateral posterior cerebral artery attack and was visually impaired. He had a hard time identifying familiar faces and shades. He also felt that the familiar building looked different, and complained that it was not possible to tell from visual information alone whether the food was cooked or the kimono fabric was soft.We assessed the patient’s visual function using real materials and material images and was diagnosed with visual texture agnosia. There are few reports of visual texture agnosia, detailed evaluation is considered important because perceiving texture is important for activities of daily living.

Any Symptom of Epilepsy in Child Age Must Be Treated Immediately

Epilepsy has always carried a negative stigma so it is extremely important for a child with epilepsy to overcome the fear of repetition of convulsions and continue living like their peers. After the first cerebral attack, parents have a huge fear of repeating the same, so it is extremely important to contact a doctor immediately. Complete treatment should be performed during hospitalization, especially in cases of head trauma or prolonged loss of consciousness. The treatment consists of electroencephalography, hematological-biochemical tests, additional specific treatment according to the anamnesis and psychological treatment. After two or more unprovoked seizures with a pathological finding of electroencephalography, a diagnosis of epilepsy is made and then it is necessary to educate parents and the child about living with this disease.

Abstract 16945: Total Artificial Heart Implantation in Patients With Intractable Ventricular Arrhythmias

Ventricular arrhythmias (VAs) are pathological rhythms that are often incompatible with life and require decisive intervention. If the rhythm is refractory to treatment or causes hemodynamic compromise, mechanical support devices may be required. Oftentimes, patients with underlying heart failure do very poorly with VAs, requiring a higher level of support than can be achieved by most devices, with the exception of LVADs and TAHs. Mechanistically, a TAH is an orthotopic pneumatic biventricular mechanical support device that requires removal of the native cardiac ventricles and replacement with two artificial ventricles. Due to the nature of the procedure, the ventricular substrate, which causes VAs, is removed and the patient receives biventricular mechanical support. This case series retrospectively follows eight patients requiring implantation of a TAH due to intractable VAs between 06/2008 and 03/2017 at VCU Health. On arrival, all patients were in multiorgan failure and requiring hemodynamic support, including a varied combination of support devices, inotropes, and/or pressors. The median time of admission to implantation was 12.6 days. Major adverse events included cerebral vascular attack (CVA), significant bleeding requiring surgical intervention, and surgical site infection. Three patients had ischemic CVAs, three had significant mediastinal hematoma resulting in tamponade requiring intervention, and two had significant operative site infections requiring antibiotics and surgery. Of the original eight patients, six went on to undergo an orthotopic heart transplant, all were alive at one year follow-up. While adverse events can be serious and should be considered when evaluating for implantation, the use of a TAH can be beneficial in patients with intractable VAs and can be used to successfully stabilize patients who would otherwise perish.

Abstract 17018: Left Ventricular Assist Device Failure With Total Artificial Heart Bridge to Heart Transplant

Mechanical support devices are used in cardiogenic shock as a bridge to heart transplantation (OHT) or as a destination treatment. The two long term variants are left ventricular assist devices (LVADs) and total artificial hearts (TAHs). Developed in tandem, LVADs have gained favor, but are not without limitations. Adverse events include thrombosis, bleeding, mechanical failures, ventricular arrhythmias (VAs), and right ventricular failure (RVF). When LVADs fail, often the only options becomes OHT or TAH implantation. This case series retrospectively follows ten patients requiring TAH implantation due to LVAD failure between 12/2009-09/2018 at VCU Health. On admission, all were in multiorgan failure with four requiring hemodialysis and two requiring intubation. Eight patients required extra support including pressors, inotropes, and additional mechanical support. The causes of failure included refractory infection, outflow graft mechanical compromise, right ventricular failure, VAs, and pump thrombosis. The mean time from admission to TAH was 13.5 days. Major adverse events included mediastinal hematoma with tamponade in three patients requiring surgical intervention and one patient with an acute cerebral vascular attack who died. One patient died from ongoing respiratory failure. Another patient died from multiorgan failure and hemorrhage. Of the seven surviving patients, all underwent successful OHT and were alive at one year follow-up. The patients who experience LVAD failure are extremely sick and have limited options. TAH implantation, while not without risk, can be a useful tool to bridge patients to transplant with favorable outcomes.

Regorafenib as second line therapy for imatinib-resistant gastrointestinal stromal tumor (GIST): A phase II study

Abstract Background Standard first line treatment for metastatic/recurrent gastrointestinal stromal tumor (GIST) is imatinib; however eventually almost all the GISTs become resistant to imatinib. Secondary mutation in KIT is the most relevant cause of imatinib-resistant, as high as 70% of cases. Sunitinib is the current standard second line treatment for imatinib-resistant GIST with median progression-free survival (PFS) of 24.6 weeks; however, in a preclinical study sunitinib is not active for approximately half of secondary mutant GIST. Regorafenib is active for some secondary mutations resistant to sunitinib in the preclinical study. Therefore, we conducted a prospective phase II study of regorafenib as second line therapy for imatinib-resistant GIST. Method Patients with imatinib-resistant metastatic/recurrent GIST were eligible for the current study. Other key inclusion criteria included patients with ECOG performance status of 0-1 and adequate organ function. Patients treated with sunitinib were excluded. The primary endpoint was PFS rate at 24 weeks. Tumor response, safety, and biomarkers were also analyzed. Results A total of 38 patients were enrolled as planned. Median age was 64.5 (39 - 80). Twenty-five patients were male. Primary site was stomach in 17, small intestine in 16. Best overall response was PR for 5 (13%), SD for 24 (63%) and PD for 6 (16%) patients, with response rate of 13%. Grade 3 or more adverse events (AE) were observed in 25 (66%) patients. Common grade 3 or more AE were hand-foot syndrome (n = 9), hypertension (n = 9), hepatotoxicity (n = 4), thrombocytopenia (n = 2), and proteinuria (n = 2). There was one treatment-related death (cerebral attack). The primary endpoint of PFS will be presented at the conference. Conclusion Regorafenib demonstrated promising activity in patients with imatinib-resistant GIST as second line therapy with acceptable toxicity.

Outcome prediction models in AQP4-IgG positive neuromyelitis optica spectrum disorders.

Pathogenic antibodies targeting the aquaporin-4 water channel on astrocytes are associated with relapsing inflammatory neuromyelitis optica spectrum disorders. The clinical phenotype is characterized by recurrent episodes of optic neuritis, longitudinally extensive transverse myelitis, area postrema attacks and less common brainstem and cerebral events. Patients often develop major residual disability from these attacks, so early diagnosis and initiation of attackpreventing medications is important. Accurate prediction of relapse would assist physicians in counselling patients, planning treatment and designing clinical trials. We used a large multicentre dataset of 441 patients from the UK, USA, Japan and Martinique who collectively experienced 1976 attacks, and applied sophisticated mathematical modelling to predict likelihood of relapse and disability at different time points. We found that Japanese patients had a lower risk of subsequent attacks except for brainstem and cerebral events, with an overall relative relapse risk of 0.681 (P = 0.001) compared to Caucasians and African patients, who had a higher likelihood of cerebral attacks, with a relative relapse risk of 3.309 (P = 0.009) compared to Caucasians. Female patients had a higher chance of relapse than male patients (P = 0.009), and patients with younger age of onset were more likely to have optic neuritis relapses (P < 0.001). Immunosuppressant drugs reduced and multiple sclerosis disease-modifying agents increased the likelihood of relapse (P < 0.001). Patients with optic neuritis at onset were more likely to develop blindness (P < 0.001), and those with older age of onset were more likely to develop ambulatory disability. Only 25% of long-term disability was related to initial onset attack, indicating the importance of early attack prevention. With respect to selection of patients for clinical trial design, there would be no gain in power by selecting recent onset patients and only a small gain by selecting patients with recent high disease activity. We provide risk estimates of relapse and disability for patients diagnosed and treated with immunosuppressive treatments over the subsequent 2, 3, 5 and 10 years according to type of attack at onset or the first 2-year course, ethnicity, sex and onset age. This study supports significant effects of onset age, onset phenotype and ethnicity on neuromyelitis optica spectrum disorders outcomes. Our results suggest that powering clinical treatment trials based upon relapse activity in the preceding 2 years may offer little benefit in the way of attack risk yet severely hamper clinical trial success.

Recurrent cerebral attack caused by thrombosis in the pulmonary vein stump in a patient with left upper lobectomy on anticoagulant therapy: case report and literature review

BackgroundThrombus formation in the pulmonary vein stump after pulmonary resection has recently been identified as a cause of systemic thrombosis including brain infarction. However, there is limited research focusing on the clinical course of pulmonary vein stump thrombus, and optimal treatment and prevention strategies of this important complication have not been established.Case presentationA 77-year-old woman was diagnosed with lung cancer of the left upper lobe, cT4N2M0, cStage IIIB. As the tumor was considered to be completely resectable, the patient underwent a left upper lobectomy with angioplasty of the left pulmonary artery. The final pathological stage was pT4N2M0, pStage IIIB. The patient developed paralysis of the right upper limb and dysarthria on the 8th postoperative day. Diffusion-weighted magnetic resonance imaging (MRI) of the brain showed multiple high-intensity signals in the area of the left middle cerebral artery, which were not detected on preoperative MRI. She was diagnosed with a cerebral infarction and started on acute-phase treatment including anticoagulation with continuous intravenous heparin infusion. The neurological symptoms improved the following day. Contrast-enhanced chest CT scan revealed thrombus in the left superior pulmonary vein stump measuring 10 mm in diameter. She had no comorbidity related to the cerebral attack. After the treatment was initiated, her symptoms became stable. However, symptoms of altered consciousness, dysarthria, and hemiparesis re-occurred on the 19th postoperative day and improved within an hour. The thrombus in the left superior pulmonary vein stump disappeared on follow-up contrast-enhanced chest CT performed the same day.ConclusionsThis is the first report of recurrent brain attack caused by thrombosis in the pulmonary vein stump in a patient receiving anticoagulant therapy. The present case suggests the possibility of thrombus mobilization causing recurrent systemic thrombosis, and this important complication needs to be considered in future clinical practice.

Abstract TP199: Stroke Awareness in Argentina, the Sifhon Population Survey

Introduction: Stroke awareness in Latin America is scant. We conducted a large population survey in 13 provinces in Argentina to assess knowledge of cerebrovascular disease. Methods: We distributed 110,000 multiple-choice anonymous questionnaires using the house distribution system of a bottled water dispensing company, assessing information regards age, gender, educational level, general stroke information, attitude towards symptoms and treatment. Percentages of each choice were recorded for every question and a multivariate analysis was performed. Results: A total of 12,710 surveys were returned, age 51±17 years, 69% women. Almost 95% reported prior knowledge of the disease, 50% through public media, 37% through a relative/friend that had a stroke and 8% through their family doctor. The Spanish acronym for accidente cerebrovascular , ACV, was the most frequently identified name for stroke (79%), the Spanish equivalent to cerebral attack was used by 7% and 0,4% used the term “ictus”. Only 29% knew about TIA but 69% identified stroke risk factors. Although 73% recognized their signs and symptoms, 11% misinterpreted them as a heart attack and 34% ignored that stroke can present with severe headache. Although 73% considered the disease potentially disabling/fatal, 40% ignored its frequency. If symptoms, 25% would call 911 and 50% would go to an emergency room by own means. Only 63% knew the existence of a specific treatment. Lowest degree of knowledge was seen in young, single, non-university men. Conclusion: This study represents the largest general public stroke awareness survey in Spanish speaking populations. Respondents showed excellent recognition of risk factors, warning signs and need of a rapid response. The population had little knowledge of prevalence, severity, TIA, and acute treatment. Public media appear to have an essential role in education.

Ендотеліальна дисфункція при немедикаментозній гірудотерапії в поєднанні з мануальною та нутриціологічною корекцією у хворих із транзиторними ішемічними церебральними атаками

Ендотеліальна дисфункція при немедикаментозній гірудотерапії в поєднанні з мануальною та нутриціологічною корекцією у хворих із транзиторними ішемічними церебральними атаками

Patent foramen ovale: indications for closure and techniques.

Non-surgical closure of the patent foramen ovale (PFO) has been possible for 40 years and proved safe in probably a million cases performed worldwide. Nonetheless, indications are still restricted as only a few are supported by randomised data. Paradoxical embolism through a PFO causes stroke, myocardial infarction, and visceral or peripheral ischaemia. The PFO is a likely mediator of migraine, diving or high altitude sickness, dyspnoea, and sleep apnoea problems. As untoward effects of a PFO are rare and spaced widely timewise, large cohorts and long follow-ups are required to prove unequivocally that PFO closure is bene-ficial and appropriate in comparison to no treatment or medical therapy. The most compelling respective randomised data have been gathered so far in the realm of secondary prevention of cerebral attacks and migraine. Invariably they showed a numerical advantage of PFO closure with significant difference in sub-analyses. Evidence-based medicine carries a danger of underutilising valuable therapies while accumulating further data. PFO closure is an example. Its documented innocuousness invites a more proactive reflection in upcoming guidelines. At worst, PFO closure may not convey the projected amount of benefit. This even opens the door for primary prevention in some PFOs with high-risk characteristics.

GC-Rich DNA Fragments and Oxidized Cell-Free DNA Have Different Effects on NF-kB and NRF2 Signaling in MSC.

It has been established that cell-free DNA circulating in the bloodstream affects cells. The characteristics of cfDNA depend on the physiological state of the organism. As we showed previously, diseases can cause either GC-enrichment of the cell-free DNA pool or its oxidation. Thus, in cases of cerebral atherosclerosis, heart attack and rheumatic arthritis the cell-free DNA pool is GC-enriched and, in the case of cancer, both GC-enriched and oxidized. Herein we investigated the time-dependent effect of oxidized and GC-rich cell-free DNA on NF-kB and NRF2 signaling pathways in human mesenchymal stem cells and showed that they affect cells in different ways. Oxidized DNA drastically increases expression of NRF2 in a short period of time, but the effect does not last long. GC-rich DNA causes a prolonged increase in mRNA levels of NF-kB and NRF2 which lasts 48 and 24 h, respectively.

Brain CT Findings in First Episode Depression in Older Adults

Introduction: Different studies reported the strong relationship between cerebrovascular changes (CVC) and depression. Moreover, many researchers tried to correlate between the pathogenesis and location of the CVC and severity of depression. Methods: In this study we looked for the possibility of presence of CVC in patients with an age ranging from 60 - 75 years, presented to psychiatric clinics and hospitals in Hail, Saudi Arabia and diagnosed for the first time with depression. All patients have been diagnosed neither with cerebral attacks (CA) nor with depression. A cross sectional study was done on 149 patients. Hamilton rating scale (HRS) for depression was used to evaluate the severity of depression before staring any treatment. National institutes of health stroke scale (NIHSS) was applied for all the patients to exclude any possibility of CA. Brain CT was done to all patients to detect an evidence of CVC. Results: According to the CT findings, the patients were divided into four groups: Group 1 with normal CT findings; Group 2 with ischemic changes; Group 3 with single lacunar infraction; and Group 4 with multiple lacunar infarctions. After analyzing the results and correlating the severity of depression and CT findings in the four different groups we found significance in the correlation between severity of depression and the presence of minor strokes. Conclusions: A first episode of depression in older adult patients may indicate the presence of minor or silent stroke or CA.

Long-term clinical outcome of patients who failed catheter ablation of atrial fibrillation.

Left atrial ablation fails to prevent symptomatic recurrences of atrial fibrillation (AF) in 20-30% of patients up to 3 years of follow-up despite multiple procedures. Data are lacking on the long-term clinical outcome of those patients for whom the decision was taken to renounce performing further ablation procedures. In this multicentre study, 218 (34%) of 631 consecutive patients, who had undergone AF catheter ablation in the years 2001-11 for drug-refractory symptomatic AF, had symptomatic AF recurrences after 1.5 ± 0.6 procedures. Their long-term clinical outcome was assessed in March 2012 (minimum follow-up 1 year). At a mean of 5.1 ± 2.6 years since their last ablation, 82 (38%) patients improved, 103 (47%) remained unchanged and 33 (15%) worsened, but only 17 (8%) had such a severe impairment of their quality of life as to require atrioventricular junction ablation and pacing (#13) or cardiac surgery (#4); 22 (10%) patients had had adverse clinical events (death in five, heart failure in five, stroke and transient ischaemic cerebral attack in four, severe haemorrhage in four, pacemaker or implantable cardioverter-defibrillator implantation in seven) and 98 (45%) patients had developed permanent AF. Compared with patients without permanent AF, fewer patients with permanent AF improved (3% vs. 66%, P = 0.001) and more got worse (28% vs. 5%, P = 0.001). At multivariable logistic regression, single ablation procedure, left atrial diameter, persistent AF and time from the last ablation were independent predictors of permanent AF. More than 5 years after a failed AF ablation, a small minority of patients had such an impaired quality of life as to require non-pharmacological interventions. Almost half developed permanent AF, which significantly impaired quality of life. Permanent AF was more common in patients who had left atrial enlargement, history of persistent AF, longer follow-up, and had performed a single ablation procedure, thus hypothesizing that reablation could reduce the chronicization of arrhythmia. A low risk of stroke was observed in the long-term follow-up.

Role of Carotid Endarterectomy Following Intravenous Thrombolysis

placebo controlled trials. 2 Infusion of rt-PA is beneficial within 4.5 hours of stroke onset in appropriate individuals. While one may quibble with the definition of stroke requiring 24 hours, these studies excluded minor or resolving neurological symptoms suggesting that transient ischemic attacks were not treated with rt-PA during the trials. It is unknown if indications for lysis have expanded following its widespread introduction into clinical practice. How often is extracranial carotid stenosis found following rt-PA for acute strokes? Although their initial workup routinely included a duplex ultrasound, the incidence of carotid stenosis in the acute rt-PA population of their two referring institutions is unknown. Likewise, the frequency of carotid stenosis was not reported in the pooled trials validating rt-PA. 2 The low incidence of 6% in Bartoli’s report is substantially less than the 20-30% estimated by Rothwell. 3 Treatment for acute cerebral attacks has focused on intravenous rt-PA. In an effort to improve the limited success of IV rt-PA, three recent trials randomized concomitant aggressive, intracranial endovascular therapies. No significant benefit beyond rt-PA was found. 4 Bleeding is a major surgical concern. The 5 minute halflife of alteplase is unlikely to affect an operative event several days later. Aggressive antiplatelet therapy offers potential for mischief in the OR. However, the unknown risk is hemorrhagic conversion of a cerebral infarct. Eligibility for rt-PA requires a head CT to exclude hemorrhage; of note, intracerebral hemorrhage following rt-PA was reported in 33%, but most were presumably asymptomatic. 2 The one reported morbidity resulting from CEA following rt-PA therapy was attributed to hemorrhagic conversion; the dramatic finding of a floating thrombus in conjunction with a tight carotid stenosis following rt-PA therapy was the rationale for CEA at 33 hours. 3 Balancing this unknown risk against the benefits of CEA within a 2-week time frame may be the essence of the question raised by this report. Strict, intensive control of blood pressure is recommended to decrease the risk of hyperperfusion syndrome. 1e3 As lytic therapy for stroke becomes more common, vascular surgeons throughout the world will be asked to consider CEA in this setting. Since we really do not know whether post-rt-PA patients are different from those with stable strokes, and since recruitment of a sufficiently large study group is daunting, a randomized trial is unlikely. Thus, registry reports or additional reports like this are needed to establish rational guidelines for surgical intervention. While the numbers are small (N ¼ 49), the combined data presented here suggest that CEA may be beneficial.

How Epidemiology of Polycythemia Vera Has Changed in the Last 10 Years: Results From the Whole Prospective Cohort of Patients in Cyto-PV Trial As Compared with Eclap Prospective Cohort

AbstractAbstract 1748 Introduction:Polycythemia vera (PV) is a chronic myeloproliferative neoplasms characterized by erythrocytosis, vasomotor disturbances, pruritus, risk of disease progression into acute myeloid leukemia or myelofibrosis and cardiovascular events, the last representing the main cause of morbidity and mortality. Since 2005 the V617F point mutation in Janus Kinase 2 (JAK2) gene gained a dominant role in determining the molecular basis and the diagnosis of PV. We compared the clinical epidemiology of the 1638 patients included in the ECLAP trial in the years 1997 to 2001, with that of a “modern” cohort of 365 PV, JAK2-positive patients included in the Italian CYTO-PV randomized clinical trial and followed from the year 2008 to 2012. Methods:Patients were eligible in CYTO-PV trial and in ECLAP study if they met WHO-2008 diagnostic criteria and the criteria established by the PVSG or Pearson/Messinezy respectively. Clinical characteristics have been compared. The incidence of major cardiovascular events (CV death plus major thrombosis [stroke, acute coronary syndrome, transient ischemic cerebral attack, peripheral arterial thrombosis, pulmonary embolism, abdominal thrombosis, deep vein thrombosis) and total CV events incidence has been evaluated. The median follow up was 31.0 months (range 0– 48.13 months) and 33.1 months (range 0–63.6) for patients included CYTO-PV and in ECLAP respectively. Results:In CYTO-PV 49.3% patients with recent PV diagnosis were included (within 2 years prior inclusion) while in ECLAP the proportion was 35.5%. Mean age at recruitment was similar for patients in CYTO-PV (64.5 yrs) and ECLAP (65.4 yrs). History of thrombosis was reported in 28.9 % vs 38.6% patients in the CYTO-PV and in ECLAP, respectively (p<0.05). Consistently higher proportions of arterial and venous thrombotic events were found in ECLAP as compared to CYTO-PV. History of major bleeding was reported in 1.7% vs 4.8% of the patients in CYTO and ECLAP, respectively. Medical treatment at recruitment was more intensive in CYTO-PV vs. ECLAP: phlebotomy 72.3% vs 63.5% (ns), hydroxyurea (HU) 54.2 vs 48.4, antiplatelet drugs 84.9% vs 58.3% (p<0.05), aspirin 77.0% vs 50.2% (p<0.05), anti-hypertensive and hypocholesterolemic medications were administered respectively in 48.5% and 13% of CYTO–PV patients vs. 39% and 3.5% of ECLAP population (p<0.05) As compared with ECLAP, the incidence of risk of major thombosis in CYTO-PV was 2.7 vs 4.4 and of total CV events was 3.4 vs 5.5 per 100 person/years, respectively. The incidence of total CV events in CYTO-PV for the subgroups of patients with age <65 and no previous thrombosis (PT), age > 65 and no PT, age <65 and PT, age > 65 and PT at randomization was 2.2, 4.8, 3.5 and 3.4 per 100 person/years, respectively. Conclusions:The comparison of these two cohorts of PV patients followed 10 years apart suggests that JAK-2 PV patients are currently better managed for the control of classical CV risk factors, are more frequently administered aspirin, and HU with better control of their disease, and eventually have a risk of thrombosis approximately half than in the past. Disclosures:No relevant conflicts of interest to declare.