Cerebrovascular Infarction Research Articles

Features of Cerebral Infarction Due to Left Ventricular Thrombus.

Objective Left ventricular (LV) thrombus is a rare condition in acute cerebral infarction. The prevalence and features of cerebral infarction with LV thrombus are unclear. We explored the features of cerebral infarction due to LV thrombus. Methods In this single-center retrospective study, we investigated consecutive patients with acute ischemic stroke admitted within seven days of the onset who had LV thrombus found by transthoracic echocardiography (TTE). First, we calculated the prevalence of LV thrombus in patients with cardioembolic stroke (CES). Second, we investigated the baseline characteristics, including the TTE findings and features of cerebral infarction due to LV thrombus. Results From June 2012 to January 2019, a total of 5,693 patients were enrolled. Of these, 1,408 (25%) patients were diagnosed with CES. Of these 1,408 patients with CES, 13 (0.9%) had LV thrombus indicated by TTE, with dilative cardiomyopathy, subacute myocardial infarction, and old myocardial infarction present in 1 (8%), 2 (15%), and 10 (77%), respectively. The ejection fraction (EF) was 48.9% (25.3-64.7%). The maximum longitudinal size of LV thrombus was 13.4 (0.97-38.1) mm, and there was no correlation between the size of the LV thrombus and the EF. Regarding the features of cerebrovascular infarction, major vessel occlusion was observed in 10 (77%) patients. Six (46%) patients were found to have good outcomes (modified Rankin Scale 0-2) at 90 days after the onset. Conclusion LV thrombus was seen in 0.9% of patients with CES. Many of the patients with LV thrombus had major vessel occlusion.

Maternal and neonatal outcomes among pregnant women with cardiovascular disease in the Philippines: a retrospective cross-sectional study from 2015–2019

Purpose Several studies link maternal cardiovascular disease (CVD) to maternal and fetal morbidity and mortality. This study describes the profile of maternal, obstetric, and neonatal outcomes among pregnant women with CVD in a tertiary hospital in the Philippines. It identifies the clinical and sociodemographic variables associated with these outcomes. Materials and Methods A single-center, retrospective analysis of pregnant women admitted for delivery at the Philippine General Hospital from 2015 to 2019 was performed. Of these patients, pregnant women with CVD were identified as the cohort for this study. Data on clinical and sociodemographic factors, maternal major adverse cardiovascular events, neonatal adverse clinical events, and obstetric complications were collected. Logistic regression analysis was performed to determine the odds ratio for the risk factors for small-for-gestational-age (SGA) babies and preterm birth. Results Among 30,053 delivery admissions in the Philippine General Hospital from 2015 to 2019, 293 (0.98%) pregnant women had CVD. Of the CVDs present in this cohort, congenital heart diseases (n = 119, 40.6%) were the most common, followed by rheumatic heart disease (n = 109, 37.2%). Maternal adverse events were rarely observed. Four women experienced symptomatic arrhythmias, two presented with worsening heart failure, three experienced thromboembolic events, and one had cerebrovascular infarction. There was no reported maternal death, cardiac arrest, shock, or acute renal failure. The majority (69.3%) of the women included in the study were delivered by spontaneous vaginal delivery and assisted vaginal delivery by vacuum or forceps; however, a significant portion of these women had undergone cesarean section. Almost all the study cohort delivered live births, with most neonates being delivered at 37–38 weeks gestational age (83.6%) and only 16.0% born preterm. However, a significant portion, a third of the neonates, were classified as having low birth weight. Around 17.4% of neonates born from gravidocardiac mothers were admitted neonatal intensive care unit. Conditions associated with preterm birth were low educational attainment, previous history of early neonatal death, maternal low ejection fraction, and abnormal maternal left ventricular geometry. The conditions associated with SGA babies were high gravidity and parity, a history of abortion/stillbirth, a history of previous cesarean section delivery, low ejection fraction, a history of multiple gestations, and higher BMI. Conclusion In this cohort study, adverse maternal outcomes were rarely observed. CVD in pregnancy is associated with an increased risk of preterm birth and SGA babies. We identified certain maternal conditions and sociodemographic factors associated with these outcomes. Despite having CVD, our study cohort had no mortality from the pregnancy.

Interpretation of infarct location in relationship to perfusion territories using territorial arterial spin labeling in a patient with multiple infarctions: A case report

We, herein, describe a 50-year-old man with steno-occlusive cerebrovascular disease and multiple infarcts that were expected to be within the perfusion territories of the basilar artery (BA) and left internal carotid artery. However, territorial arterial spin labeling (T-ASL) perfusion magnetic resonance imaging showed that the infarct lesions were only located in the perfusion territory of the BA and confirmed the stroke etiology of large artery atherosclerosis. This case implies that the diagnostic information provided by T-ASL is valuable for identifying the symptomatic perfusion territories and stroke etiology. This technique is, therefore, able to guide therapeutic management in patients with multiple infarcts.

Brain Magnetic Resonance Imaging and Angiography in Children with Sickle Cell Anaemia in Uganda in a Cross-Sectional Sample

Children with sickle cell anaemia (SCA) are highly susceptible to cerebrovascular injury. We performed brain magnetic resonance imaging and angiography (MRI-MRA) in Ugandan children with SCA to identify structural cerebrovascular abnormalities and examine their relationship to standardized clinical assessments. A sub-sample (n=81) was selected from a cross-sectional study of children attending SCA clinic, including 52 (64.2%) with and 29 (35.8%) without clinically detected abnormalities. Clinical evaluation included assessment for prior stroke, cognitive testing and cerebral arterial transcranial doppler (TCD) flow velocity. MRI-MRA scans were interpreted by at least two neuroradiologists. Mean age was 6.5±2.7 years, with 39 (48.1%) female. Mean haemoglobin was 7.3±0.9 g/dl. Overall, 13 (16.0%) were malnourished. Infarcts and/or stenoses were detected in 55 (67.9%) participants, with stenoses primarily in the anterior circulation. Infarcts were seen in those with normal 17/29 (58.6%) or abnormal 34/52 (65.4%) clinical testing (p=0.181). Neither abnormal MRI nor MRA was associated with age, sex, haemoglobin, or malnutrition. Abnormal MRA was highly associated with infarcts (p<0.0001). Participants with abnormal imaging had two-fold higher proportion of stroke on exam and/or impaired cognition. Stroke on exam was strongly associated with an imaging abnormality after adjusting for age, sex, malnutrition, and haemoglobin (OR 11.8, 95%CI 1.87-74.2). Over half of these SCA children had cerebrovascular infarcts and/or arterial stenoses. Cerebrovascular disease was frequently undetectable by clinical assessments. While rarely available in under-resourced settings, MRI-MRA brain imaging is an important tool for defining SCA cerebrovascular disease and for assessing impact of clinical intervention trials.

Clinical profile of new-onset seizures in the elderly

Aim: The aim of the study is to determine the etiology of seizures in the elderly and types of seizure in elderly populations. Materials and Methods: This was a cross-sectional study carried out on patients of age more than 60 years with seizures and who satisfied inclusion and exclusion criteria, admitted in Bangalore Medical College and Research Institute (BMCRI) attached hospitals, Bengaluru, between November 2016 and October 2018. After obtaining ethical clearance and approval from the institutional ethics committee of BMCRI, written informed consent was taken from the patients. Detailed history was taken from all patients, and all patients underwent thorough clinical examination and investigations. The diagnostic probability was based on the clinical data obtained from the patient charts and the results of electroencephalography (EEG) and computed tomography (CT) scans. The etiology of seizures was determined on the basis of medical history, neurologic examination, EEG, and CT scans. Results: A total of 58 patients of new-onset seizure included in the study out of which 30 were male and 28 were female. Majority of the patients were aged between 60 and 70 years. Male-to-female ration was almost equal. GTCS was the major type of seizure. Cerebrovascular infarct was the most common etiology. Diabetes and hypertension (HTN) were the most common comorbid conditions. Conclusion: Seizure was the dominant manifestation of various underlying disorders in the elderly, of which cerebrovascular disease was the most common cause, followed by metabolic cause. Comorbidities such as diabetes and HTN also had an important role in seizure activity. GTCS was the most common type of seizure in the elderly.

Apophegma on population mortality due to diseases of the circulatory system in the context of the residence of the deceased as aporia in the public life of Ukraine

Objective. The establishment and substantiation of biostatistical trends in the state of mortality of the population of Ukraine due to diseases of the circulatory system (I00-I99) in the context of the place of residence of the deceased for the period 2009-2019.Material and methods. An epidemiological, one-time, continuous, prospective scientific study was carried out using statistical data of the State Statistics Service of Ukraine and the Center for Medical Statistics of the Ministry of Health of Ukraine for the period 2009-2019, where the author performed the compilation and processing in spreadsheets of Microsoft Office Еxcel (2019). Retrospective, biostatistical, mathematical, abstract and graphic research methods are used, as well as methods of copying, deductive awareness, structural and logical analysis taking into account the principles of systematicity.Results and discussion. The obtained results indicate that mortality due to DCS (I00-I99), during the studied period (2009-2019), is dominant in the overall mortality structure of the population of Ukraine, where ischemic heart disease (I20, I24-I25) ranks first in terms of mortality, especially among the inhabitants of rural areas of the country, while the following rankings: second, third, fourth, consistently and intransigently share cerebrovascular disease (I60-I69), myocardial infarction (I21-I24) and hypertension (I10-I15), which are dominant in the inhabitants of urban areas.Conclusions. Given the excessive and direct burden of DCS mortality on the quantitative expression of the country's population and its negative impact on people's quality of life, as well as the state of public health, socio-economic well-being and resource provision of society, the state of Ukraine is required to make decisive and effective priority adequate management decisions of preventive content, to minimize cardiovascular pathology (I00-I99) in the context of "European guidelines for the prevention of cardiovascular disease in clinical practice" (2016).

Survival and risk factors for premature mortality in patients with parkinson’s disease

Aim. To assess the survival rate and risk factors for premature mortality in patients with Parkinsons disease in Baku.&#x0D; Material and research methods. The observation was carried out retrospectively, information was collected on all patients (110 patients) in whom the diagnosis of Parkinsons disease was first established in 20092010. These patients are provided with drugs free of charge, which made it possible to provide them with diagnostic monitoring in polyclinics. During 20102019, 94 patients with a diagnosis of Parkinsons disease died. All medical death certificates were selected for analysis. The diagnoses in column a of these documents were accepted as direct causes of death, regardless of the presence or absence of a causal relationship of these diagnoses with Parkinsons disease. Therefore, the reported cases were interpreted not as death due to Parkinsons disease, but as the death of a patient diagnosed with Parkinsons disease.&#x0D; Results. Noteworthy is the prevalence of men (72.7%) and people without dementia (70.9%) among patients. Within 10 years, 85.5% of patients died from various causes. The immediate causes of death were acute cerebrovascular accidents (36.2%) and acute myocardial infarction (24.5%). The annual survival rate of the observed patients was high (94%; 95% confidence interval 51100%). The five-year survival rate is 76% (95% confidence interval 42100%).&#x0D; Conclusions. (1) The survival rate of patients with Parkinsons disease within 10 years after the onset of signs ranges from 0.94 to 0.41 (five-year survival rate is 0.76). (2) The immediate causes of mortality in patients with Parkinsons disease were cerebrovascular accidents (36.2%), myocardial infarction (24.5%), pulmonary embolism (11.7%), pneumonia (10.6%) and others (17%). (3) The effect of age of onset and signs of Parkinsons disease, gender, comorbidity and dementia on survival is statistically significant (p 0.05).

Abstract 11728: Common Primary Medical Conditions Associated With Secondary Takotsubo Cardiomyopathy

Introduction: Secondary Takotsubo cardiomyopathy (TCM) is considered a complication of the patient’s primary medical condition, such as medical, surgical or psychiatric conditions. More than one-third of TCM patients have primary medical conditions and tend to have a worse prognosis. However, there is no comprehensive study on the causes of TCM. Aim: We studied the common primary medical conditions in secondary TCM patients and their prognosis. Methods: We performed a retrospective analysis using the ICD-10-CM codes for a secondary diagnosis of TCM from the National Inpatient Sample database (2016-2018). We identified the primary medical condition represented by the ICD-10-CM diagnosis codes of secondary TCM patients and aggregated similar codes into clinically meaningful categories using the Clinical Classifications Software Refined. We then compared the mortality rate associated with each condition. Results: Of 14,816 patients admitted with secondary TCM, the common primary medical conditions included ‘Sepsis, unspecified organism’ (A419, 13.6%), ‘Chronic obstructive pulmonary disease with (acute) exacerbation’ (J441, 3.6%), ‘Acute respiratory failure with hypoxia’ (J9601, 2.8%), and ‘Pneumonia, unspecified organism’ (J189, 1.8%). After aggregating the individual codes into clinical categories, the common primary medical conditions included septicemia (19.1%), respiratory failure (6.4%), COPD and bronchiectasis (4.6%), hypertension with complications and secondary hypertension (4.2%), and cerebral infarction (3.1%). Primary medical conditions that yielded a higher mortality rate than the overall rate (8.5%) were septicemia (16.5%, P&lt;0.001), respiratory failure (10.7%, P=0.019), cerebral infarction (13.1%, P&lt;0.001), and acute hemorrhagic cerebrovascular disease (26.8%, P&lt;0.001). Conclusions: Sepsis is the most common primary medical condition of secondary TCM in admitted patients. Secondary TCM patients with a primary condition of acute hemorrhagic cerebrovascular disease, sepsis, respiratory failure, or cerebral infarction have higher in-hospital mortality than those with other primary medical conditions.

Abstract 11771: Co-Morbid Amyloidosis Leads to Higher In-Hospital Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement: Analysis of National Inpatient Sample

Introduction: Amyloidosis is a common comorbidity in elderly patients with aortic stenosis (AS) referred for transcatheter aortic valve replacement (TAVR). We sought to determine the impact of amyloidosis on the clinical outcomes of TAVR. Methods: Data were extracted from the National Inpatient Sample (NIS) 2016 - 2018 database. The NIS was searched for adult patients who underwent TAVR during hospitalization with and without amyloidosis as a secondary diagnosis using ICD-10 codes. The primary outcome was inpatient mortality. Secondary outcomes are shown in table 1. Periprocedural complications consisted of intra-operative hemorrhage, accidental rupture and laceration of a circulatory system organ, intra-operative cardiac functional disturbances, intra-operative cardiac functional disturbances and perioperative cerebrovascular infarction. Multivariate logistic and linear regression analysis were used accordingly to adjust for confounders. STATA software was used for analysis. Results: Of the148315 patients undergoing TAVR in 2016 - 2018, 150 (0.1%) had secondary diagnosis of amyloidosis. Mean age at the time of TAVR was comparable in both groups (79.4 years, 95% CI 76.5 - 82.3 vs. 79.6 years, 95% CI 79.5 - 79.8; p=0.865). There were 30% females in the amyloidosis group vs. 46% in the other group (p=0.081).The adjusted odds ratio (aOR) for in-hospital mortality for patients undergoing TAVR with comorbid amyloidosis than those without amyloidosis was 4.77 (95% CI 1.06 - 21.49, p=0.042). Patients with amyloidosis had a similar mean difference in length of stay and total hospital charges. Comorbid amyloidosis was not associated with higher odds of peri-procedural cardiovascular complications (aOR: 1.18, 95% CI 0.36 - 3.82, p=0.786). Detailed outcomes are listed in table 1. Conclusions: Comorbid amyloidosis leads to higher inpatient mortality but similar rates of peri-procedural cardiovascular complications in patients undergoing TAVR.

Cerebrovascular Infarction Presenting as Bilateral Internuclear Ophthalmoplegia in a 75 y/o Patient

Objective To present a case of Bilateral Internuclear Ophthalmoplegia in a 75yo patient Case Description A 75 year old, Filipino, male, known hypertensive for 10 years, but not compliant to medications, presented with a sudden onset binocular horizontal, diplopia and bilateral exotropia associated with dizziness. No other symptoms like slurring of speech, body weakness, numbness were noted. Primary gaze exotropia, abduction nystagmus, gaze evoked vertical nystagmus were also noted. Imaging was done which revealed hypodense focus in the subcortical region of the right centrum semiovale extending to the right corona radiata, with unremarkable orbits, midbrain and pons findings. WEBINO was still considered even without the presence of a pontine lesion in the imaging. The patient was advised patching and was asked to follow up after a month

Fatal large-vessel cerebrovascular infarct presenting with severe coronavirus disease 2019 in a 39-year-old patient: a case report

BackgroundEmerging reports are describing stroke in young, otherwise healthy patients with coronavirus disease 2019, consistent with the theory that some of the most serious complications of coronavirus disease 2019 are due to a systemic coagulopathy. However, the relevance of both the severity of coronavirus disease 2019 illness and established vascular risk factors in these younger patients is unknown, as reports are inconsistent.Case presentationHere we describe a 39-year-old white male, who died after presenting simultaneously with a malignant large-vessel cerebrovascular infarct and a critical coronavirus disease 2019 respiratory illness. Doppler ultrasound revealed evidence of carotid plaque thrombosis. Blood tests revealed evidence of undiagnosed diabetes mellitus; however, the patient was otherwise healthy, fit, and active.ConclusionsThis unique case highlights a possible interaction between established risk factors and large-vessel thrombosis in young patients with coronavirus disease 2019, and informs future research into the benefits of anticoagulation in these patients.

On-admission versus in-hospital thromboembolism due to COVID-19 infection. What is the particular characteristic of those with early thrombotic events?

Increasing evidence has declared a hypercoagulable state in the coronavirus 2019 infection (COVID-19), while the etiology has remained a question. For the first time, the current study has aimed to compare the contributors of thromboembolism among those whose primary manifestations of COVID-19 were thrombosis vs the patients with a thrombotic event during the period of hospitalization. This case-control study has been conducted on 267 COVID-19 patients, including 59, 48, and 160 ones with an on-admission, in-hospital, and without a thrombotic event, respectively. The events were defined as deep vein thrombosis (DVT), ischemic cerebrovascular accidents (CVA), pulmonary thromboembolism (PTE), or acute myocardial infarction (AMI). The demographic, physical examination, clinical and laboratory assessments of the groups were compared. The DVT (OR: 5.18; 95% CI: 1.01-26.7), AMI (OR: 11.1; 95% CI: 2.36-52.3), and arterial thrombosis (OR: 5.93; 95% CI: 0.63-55.8) were significantly associated with an on-admission thrombosis compared to those who presented in-hospital events. Lower levels of oxygen saturation were the only significant predictor index inversely associated with on-admission thrombosis compared to those with an event during the hospital admission period. PTE development was the most common in-hospital thrombotic event, whereas other thromboembolism types were remarkably more often among cases with on-admission events. Oxygen saturation was the only predictor of premature thrombosis that was inversely associated with outpatient events.

Developmental Trajectories of Early Higher‐Order Thinking Talk Differ for Typically Developing Children and Children With Unilateral Brain Injuries

ABSTRACTThe use of higher‐order thinking talk (HOTT), where speakers identify relations between representations (e.g., comparison, causality, abstraction) is examined in the spontaneous language produced by 64 typically developing (TD) and 46 brain‐injured children, observed from 14–58 months at home. HOTT is less frequent in lower‐income children and children with brain injuries, but effects differed depending on HOTT complexity and type of brain injury. Controlling for income, children with larger and later‐occurring cerebrovascular infarcts produce fewer surface (where relations are more perceptual) and structure (where relations are more abstract) HOTT utterances than TD children. In contrast, children with smaller and earlier occurring periventricular lesions produce HOTT at comparable rates to TD children. This suggests that examining HOTT development may be an important tool for understanding the impacts of brain injury in children. Theoretically, these data reveal that both neurological (size and timing of brain injury) and environmental (family income) factors contribute to these skills.

A RARE CAUSE OF PARAPLEGIA: DISTRIBUTIVE SHOCK CAUSING BORDER ZONE STROKES

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Simultaneous bilateral cerebrovascular infarction is relatively uncommon and is an entity seen rarely in watershed cerebral infarctions which occur at the border between cerebral vascular territories in the setting of severe hypotension. CASE PRESENTATION: 84-year-old male with history of CAD, cerebellar stroke, peripheral arterial disease was admitted to the ICU with distributive shock and intubated for toxic metabolic encephalopathy. Initial CT head on admission was unremarkable. On day 2 of hospitalization his neuro assessment was notable for bilateral lower extremity paresis with preservation of sensation, proprioception and temperature but had sluggish reflexes and loss of motor strength. Repeat CT head did not show a bleed and subsequently, MRI brain with MRA head and neck revealed bilateral acute anterior cerebral artery strokes. Given the location and duration of symptoms he was not a TPA candidate and was treated with medical management with aspirin and statin. Echocardiogram and carotid ultrasounds were done that were unremarkable for embolic cause of stroke. DISCUSSION: The anterior cerebral artery is a major vessel supplying blood to the interhemispheric region. ACA territory infarction accounts for only 0.3% to 4.4% of cerebral infarctions. Bilateral ACA infarction is even rarer. Twenty-seven cases of ACA territory infarction were reported among 1490 cases of cerebral infarction in the Lausanne Stroke Registry; among them, only two cases had bilateral ACA territory infarction. Bilateral ACA infarction can occur due to vasospasm in the setting of subarachnoid hemorrhage caused by a rupture of aneurysms of the anterior communicating arteries or distal ACAs, thrombosis or embolism in case of anomaly of circle of Willis or bilateral anaplastic ACAs. In our patient the area of infarction was in a watershed zone bilaterally, unfortunately affected by hypotension which is rare in the absence of any of the above-mentioned anomalies as predisposing factors. The true incidence of bilateral ACA infarction is unknown, with few cases reported in the literature. CONCLUSIONS: This case report highlights the possibility of developing simultaneous bilateral cerebral infarctions in the setting of profound systemic hypotension and shock, especially if the patient has baseline chronic small vessel changes. REFERENCE #1: Orlandi G, Moretti P, Fioretti C, Puglioli M, Collavoli P, Murri L. Bilateral medial frontal infarction in a case of azygous anterior cerebral artery stenosis. Ital J Neurol Sci. 1998;19:106–108. doi: 10.1007/BF02427567. [PubMed] [CrossRef] [Google Scholar] REFERENCE #2: Gacs G, Fox AF, Barnett HJ, Vinuela F. Occurrence and mechanisms of occlusion of the anterior cerebral artery. Stroke. 1983;14:952–959. [PubMed] [Google Scholar] REFERENCE #3: Bogousslavsky J, Regli F. Anterior cerebral artery territory infarction in the Lausanne Stroke Registry. Clinical and etiologic patterns. Arch Neurol. 1990;47:144–150. [PubMed] [Google Scholar] DISCLOSURES: No relevant relationships by Imama Ahmad, source=Web Response No relevant relationships by Christine Blaski, source=Web Response No relevant relationships by Sneha Lakshman, source=Web Response

Neurological complications associated with coronavirus disease-2019 (COVID-19): MRI features

Severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) is an RNA virus, which is a strain of Severe Acute Respiratory Syndrome-related CoronaVirus (SARSr-CoV), of Coronavirus family. On 31 December 2019, a cluster of cases of unknown pneumonia in Wuhan-China was reported to the World Health Organization (WHO) that subsequently spreading as coronavirus disease 2019-(COVID-19) pandemic worldwide. On 12 January 2020, novel SARS-COV-2 was declared the cause of COVID-19 from the initial analysis of the virus genetic sequences obtained from lower respiratory tract specimen of 41 patients admitted to a designated hospital in Wuhan. The classical COVID-19 presentation is respiratory symptoms. Neuroradiological findings were reported. Our aim is to document neurological complication of COVID-19. We observed confirmed 23 COVID-19 patients presented with severe neurological symptoms. Brain-MRI showed predominately; cerebrovascular thromboembolism-related acute infarcts, autoimmune-meningoencephalitis, Acute disseminated encephalomyelitis (ADEM)-like white matter lesions. ConclusionDifferent neurological presentations are associated with COVID-19, necessitating further studies to clarify the mechanism of its CNS involvement.

Cerebrovascular Infarcts in the Setting of Disseminated Intravasulcar Coagulation As Presenting Symptom in Acute Promyelocytic Leukemia

Introduction:Patients with newly diagnosed Acute Promyelocytic Leukemia (APL) commonly present with disseminated intravascular coagulation (DIC) that can lead to hemorrhagic insult. Hematologists caring for APL patients understand that aggressive transfusion support with platelets, cryoprecipitate, and fresh frozen plasma must be initiated to correct the underlying DIC. Rarely, a patient with APL will present with arterial thrombosis in the setting of DIC and little is known about how to best manage these patients.On review of the literature, five cases were described where patients with newly diagnosed APL presented with CNS arterial thrombosis; 3 patients are alive with neurologic deficit and 2 are dead. (Table 1).We have experience with three patients diagnosed with APL who presented with cerebrovascular infarct. We report our experience to heighten awareness of this unusual presentation of this rare type of leukemia.Methods:Chart review was conducted with IRB approval on three patients with known diagnosis of APL who presented to Emory University with signs and symptoms of stroke who were found to have ischemic cranial events. Demographics, past medical history, and treatment regimen for both infarction and APL were collected.Case Series:Patient 1- 21-year-old male who presented to an outlying hospital with expressive aphasia. MRI scan showed large right temporoparietal infarction. Labs showed WBC 21.6, platelets 9,000, low fibrinogen, elevated PT and elevated d-dimer. High-risk APL was confirmed and ATRA and IV dexamethasone were started. Heparin drip was initiated to decrease risk of further ischemic insult. Worsening neurologic symptoms 4 days later led to a repeat MRI scan, which showed progressive right sided infarct and a new infarct in the left distal territory of the middle cerebral territory and expired shortly thereafter. Images 1 and 2 show infarcts on day 2 and 6 of admission.Patient 2- 55-year-old female with presented with dysarthria and altered mental status. CT head showed left middle cerebral infarction and was immediately given tPA. Her admission labs showed WBC 37.6, platelets 48,000, PT 19, aPTT 35.3, Fibrinogen 67 and a diagnosis of high risk APL was established. She was induced with ATRA, Idarubicin and ATO and discharged in hematologic remission with no neurologic deficit.Patient 3- 59 year old female, Jehovah's Witness, with multiple comorbidities presented with shortness of breath. Influenza A and PE were diagnosed and oseltamivir and warfarin was initiated. New left arm tingling prompted a brain MRI scan that showed multifocal bilateral acute infarcts. She was discharged with anticoagulation but readmitted 5 days later with a WBC of 38.4 and platelets 19,000. CT head showed progression of all the infarcts. APL was diagnosed and ATRA and ATO was started but she refused transfusions and died of neurologic deterioration.Conclusions:Our case series review is consistent with the previous literature. The mortality in patients with APL presenting with CNS arterial thrombosis is extremely high. Since it is a rare occurrence in a rare malignancy, not enough is known on the best management strategy. More dedicated observation and research is warranted on this topic to improve outcomes in this otherwise very curable malignancy. [Display omitted] DisclosuresArellano:Cephalon Oncology: Research Funding. Kota:Takeda Pharmaceuticals: Consultancy; Xcenda: Consultancy; Leukemia Lymphoma Society: Research Funding; Incyte: Consultancy; Novartis: Consultancy; Pfizer: Consultancy.

Abstract P123: Prospective Association Between Periodontal Disease And Brain Imaging Markers Of Cerebrovascular And Neurodegenerative Disease: The Atherosclerosis Risk In Communities Study

Background: Periodontal disease (PD) is associated positively with neurocognitive outcomes. Few studies have investigated the relationship between PD and indicators of brain aging and vascular changes. Hypothesis: PD is associated with greater cerebral small vessel disease, lower total and regional brain volumes and elevated β-amyloid (Aβ) deposition. Methods: We included 6,793 participants who received full-mouth periodontal examinations and tooth counts at Visit 4 (1996-1998) of the Atherosclerosis Risk in Communities Study. We used a modified 3-level version of the Periodontal Profile Class to categorize PD based on severity and extent of gingival inflammation and tissue loss. Among participants who attended Visit 5 (2011-2013), n=1,306 received a brain MRI and n=248 received a PET scan. Total brain volume, Alzheimer’s disease signature volume, and presence of microhemorrhages and cerebral infarctions were ascertained via 3T MRI; Aβ deposition was assessed from PET. We regressed brain volumes on baseline PD status using weighted multivariable linear regression. Presence of cerebrovascular microhemorrhages, infarctions, or elevated Aβ (standardized uptake value ratio&gt;1.2) were regressed on PD category using logistic models. We examined the interaction between Apolipoprotein E ε4 ( APOE ) allele possession and PD categories on the Aβ outcome. Results: Prevalence of baseline periodontal disease was 73% (959/1306) and 87% (206/248) among the MRI and PET subgroups, respectively. PD was not associated with volumetric brain measures nor microhemorrhages. PD was inversely associated with the odds of subcortical and lacunar infarctions. PD and Aβ were not associated in main effect or interaction analyses, although there was a notably stronger association among carriers of APOE . Conclusion: PD was not associated with altered brain structure, cerebral microhemorrhages or elevated Aβ deposition. Counter to the hypothesis, PD and complete tooth loss were inversely associated with cerebral infarctions.

Cerebral Embolism as a Result of Facial Filler Injections: A Literature Review.

BackgroundWith the growth in the popularity of facial filler injections, increased numbers of severe adverse events, such as cerebral embolism, have been reported.ObjectivesThe aim of this article was to summarize the clinical manifestations and proposed mechanisms of filler-induced cerebral embolism (FICE).MethodsA literature review was performed with the search keywords “filler injection,” “hyaluronic acid,” “fat graft,” “cerebral infarction,” “cerebral embolism,” “stroke,” “cerebrovascular infarction,” “disorders of consciousness,” and “hemiplegia.”ResultsAmong the 43 cases of FICE enrolled from 35 articles, 37 patients were female, and 6 were male. Twenty-nine of these patients had received fat grafting, and 12 hyaluronic acid injection. Most FICE patients had been injected in the glabella, followed by the temporal, forehead, and nasal areas. Among 30 patients injected under local anesthesia, 43.33% presented with neurologic symptoms during the procedure. The main symptoms were consciousness disorders and hemiplegia. Most of the embolization sites were in the middle cerebral artery, followed by frontal lobe infarction and anterior cerebral artery infarction. Three patients developed cerebral hemorrhage after embolism. Twenty-six patients presented with newly acquired vision loss. The management for FICE cases included embolectomy, thrombolysis, decompressive craniectomy, antiplatelet/anticoagulant therapy, and symptomatic and nutritional treatment. Nearly half of the patients recovered or exhibited improved neurologic manifestations but not visual loss. Five patients died.ConclusionsFICE is a severe complication following facial filler injection. Careful prevention, timely identification, and treatment are crucial to decreasing the morbidity and mortality of FICE.Level of Evidence: 4

A Prospective, Longitudinal Magnetic Resonance Imaging Evaluation of Cerebrovascular Reactivity and Infarct Development in Patients With Intracranial Stenosis.

Patients with symptomatic atherosclerotic and non-atherosclerotic (i.e., moyamoya) intracranial steno-occlusive disease experience high 2-year infarct rates. To investigate whether cerebral blood flow (CBF) and cerebrovascular reactivity (CVR) measures may provide biomarkers of 1-to-2-year infarct risk. Prospective, longitudinal study. Adult participants (age=18-85 years) with symptomatic intracranial atherosclerotic disease (N=26) or non-atherosclerotic (i.e., moyamoya; N=43) and stenosis ≥50% of a major intracranial artery were initially scanned within 45 days of stroke. Follow-up imaging (target =1.5 years) was acquired for new infarct assessment. 3.0 Tesla with normocapnic arterial spin labeling (ASL) and blood oxygenation level-dependent (BOLD) imaging acquired during an interleaved hypercapnic (3 minutes) and normocapnic (3 minutes) respiratory stimulus. CBF, maximum CVR, and time-to-maximum CVR (i.e., CVRDELAY ) were calculated. Laterality indices (difference between infarcted and contralesional hemispheres divided by sum of absolute values) of metrics at enrollment were contrasted between participants with vs. without new infarcts on follow-up. Laterality indices were compared using non-parametric Wilcoxon tests (significance: two-sided P < 0.05) and effect sizes as Cohen's d. Continuous variables are presented as mean ± SD. New infarcts were observed on follow-up in 15.0% of participants. The laterality index of the CVRDELAY was elevated (P=0.01) in participants with atherosclerosis with new infarcts (index=0.13) compared to participants without new infarcts (index=0.05). Elevated CVRDELAY may indicate brain parenchyma at increased risk for new infarcts in patients with symptomatic intracranial atherosclerotic disease treated with standard-of-care medical management. 2 TECHNICAL EFFICACY STAGE: 3.

A Clinical Case: the Risk Factors of Acute Kidney Injury in a Cardiological Patient

Recent epidemiological studies have demonstrated that the development of a potentially reversible moderate acute kidney injury is associated with worsening clinical outcomes and an increased risk of death. This is especially true for patients with plural comorbidities who require procedures with IV radiopaque agents. This paper presents a clinical case of an elderly patient who requires coronary angiography, and who has common clinical conditions such as hypertension, multifocal atherosclerosis with the development of renal artery disease and the presence of a history of acute cerebrovascular accident and myocardial infarction, and chronic heart failure as well. Particular attention is given to assessing the risk of developing contrast-induced acute kidney injury in patients with cardiovascular disease, as well as discussing current views on the possibility of prescribing drugs that affect the reninangiotensin system in cardiac patients with concomitant renal artery disease.