Concomitant Cerebrovascular Disease Research Articles

The decline of quantitative EEG goes along with neuropathology in Alzheimer’s Disease

AbstractBackgroundFew studies investigate the correlation between the quantitative EEG (QEEG) and the neuropathological picture. The purpose of this study is to explore how QEEG can recognize the type and extent of neuropathological changes.MethodThe EEG traces and brains belonging to 14 donors of the Abbiategrasso Brain Bank were analyzed. The subjects suffered from neurocognitive disorders due to AD, LBD or AD/vascular lesions (mixed dementia‐MD), with different stages of clinical and neuropathological severity. Clinical and neuropathological characterization was performed according to our protocol; biochemical measurements to determine the amount of proteinopathies are in runtime on frozen samples. QEEG analysis considered the relative power distribution (RPD) of the frequency bands (β, α, θ, δ) and the peak frequency (PF), i.e. the most represented frequency considering all the leads. The PF was measured every 2 seconds for 200‐400 samples, and then averaged. The Kruskall‐Wallis test was used for the comparison between groups.ResultThe clinical diagnosis included: 2 MCI, 4 AD, 6 MD, and 2 LBD. The neuropathological definite diagnosis demonstrated frequent co‐pathologies, and some discrepancies compared to the clinical diagnosis. The neuropathological characterization identified 2 cases with low AD pathology (corresponding to the 2 MCI), 8 cases with intermediate or high AD pathology (4 MD with concomitant cerebrovascular disease), and 4 cases with prevalent LBD pathology. Considering both clinical and neuropathological diagnoses, the comparison between groups revealed no significant differences in QEEG parameters. Nonetheless, a trend emerges towards a lower β‐RPD and a higher θ‐RPD in cases with prevalent LBD pathology. Grouping based on the severity of AD pathology (2 low, 4 intermediate, 4 high) demonstrated significant differences depending upon the neuropathological scoring with a progressive decrease of α‐RPD (p = 0.029) and PF (p = 0.019), and an increase of δ‐RPD (p = 0.020).ConclusionRPD and PF show low discriminatory capacity on etiology. Nonetheless, the presence of LBD seems to boost the EEG slowing. The PF slowing down parallels the increase of AD pathology, representing an indicator for the degenerative load. PF is a simple QEEG parameter, easily obtainable through standard digital EEG; it can be useful for monitoring neurodegenerative burden and disease evolution.

Gender Differences and Amputation Risk in Peripheral Artery Disease-A Single-Center Experience.

Background and Objectives: Peripheral artery disease (PAD) affects both genders, but the knowledge of clinical and therapeutic aspects particular to each gender has a prognostic value, modulating the risk of amputation and helping to reduce the risk of death or the occurrence of an acute vascular event secondary to optimal management. Materials and Methods: We conducted a retrospective, descriptive study that included 652 patients with PAD who were evaluated at "St. Spiridon" Hospital's Cardiology Department and divided into two groups according to gender: women (100 cases) and men (552 cases). We evaluated demographics, anthropometric data, as well as clinical and paraclinical parameters in the two groups. Results: Men had a lower mean age (p < 0.001), higher mean BMI (p = 0.049) and were more frequent smokers. (p = 0.008). Hypercholesterolemia (p = 0.026), obesity (p = 0.009), concomitant cerebrovascular (p = 0.005) and chronic kidney disease (p = 0.046) were more common in women, while coronary artery disease (p = 0.033) was more common in men. The number of angiographic stenotic lesions (p = 0.037) is a statistically significant parameter in our study, with both genders predominantly associated with stenotic lesions. In addition, directly proportional relationships were found between smoking, uric acid, inflammatory markers, and the number of stenotic lesions and thromboses or the ankle-brachial index (ABI). In the subgroup of men, the number of stenotic and thrombosed lesions positively correlated with the ABI value (p < 0.001). The presence of more than three cardiovascular risk factors (p = 0.001) and serum triglyceride levels (p = 0.019) significantly correlated with the number of angiographically detected lesions. We applied several risk scores (PREVENT III, Finnvasc Score, or GermanVasc risk score) in our study group for prognostic purposes, without showing statistically significant differences between genders. Men, rest pain, gangrene, smoking status, the presence of more than three cardiovascular risk factors, or a serum HDL-cholesterol level below 40 mg/dL (p < 0.001 for all parameters) are independent predictors associated with amputation in our study group. Conclusions: In our study, we demonstrated that several clinical-paraclinical particularities guide the diagnosis, providing the clinician with prognostic and therapeutic tools to choose the optimal management with maximum benefits.

Correlation of Duplex Scan and Clinical Profile of Peripheral Vascular Diseases In Dmch

Background: Duplex ultrasound is a non-invasive evaluation of blood flow in the major arteries and veins. It provides a unique spectrum of details, including the anatomical location of the lesion, accompanied by further information about flow velocity and volume. Day by day, this investigation has become popular among physicians and surgeons to evaluate peripheral arterial disease. Objective: To determine duplex scans’ accuracy in diagnosing peripheral arterial disease and correlate it with clinical diagnosis. Materials &amp; Methods: The cross-sectional study was conducted in the Department of General Surgery in collaboration with the Department of Radiology &amp; Imaging, Dhaka Medical College Hospital, and Dhaka from January 2011 to December 2011. A total of 100 clinically diagnosed cases of peripheral arterial disease, irrespective of age and sex, were included in the study. However, emergency cases of peripheral arterial disease and patients of peripheral arterial disease with concomitant cerebrovascular disease or venous pathology or arterio-venous malformation were excluded from the study. Based on clinical signs and symptoms, a clinical diagnosis was made, correlated with the diagnosis made by duplex scan findings. Result: Peripheral arterial disease was mainly confined to the lower limb (85%). The right limb was involved in about two-thirds (64%) of the cases, the left limb in 31%, and both limbs in 5% of cases. More than 90% were a smoker. Pain and intermittent claudication were the universal complaints of the patients, followed by hair changes (85%), colour changes (86%) and wasting of the limb (65%). The most commonly involved arteries in the lower limb were arteria dorsalis pedis (96.6%), followed by the posterior tibial artery (84.2%), popliteal artery (60.6%), and femoral artery (21.3%). In the upper limb, the radial artery was involved in 100% of cases and the brachial artery in 86.7% of cases. Endarteritis obliterans and atherosclerosis were common clinical diagnoses (47% and 48%, respectively). Diagnosis based on duplex scan findings also demonstrated that endarteritis obliterans and atherosclerosis were common (40% and 39%, respectively), bearing consistency with clinical diagnosis. The strength of agreement between the two diagnoses was moderate (k = 0.743). Conclusion: The study concludes that there was a moderate agreement between Clinical diagnosis and duplex diagnosis, which indicates that a duplex scan can be a valuable tool to support clinical diagnosis, suggest other diagnoses, or detect other associated pathologies. J Dhaka Med Coll. 2022; 31(1) : 98-106

Significant Mortality Associated With COVID-19 and Comorbid Cerebrovascular Disease: A Quantitative Systematic Review.

We report the first quantitative systematic review of cerebrovascular disease in coronavirus disease 2019 (COVID-19) to provide occurrence rates and associated mortality. Through a comprehensive search of PubMed we identified 8 cohort studies, 5 case series, and 2 case reports of acute cerebrovascular disease in patients with confirmed COVID-19 diagnosis. Our first meta-analysis utilizing the identified publications focused on comorbid cerebrovascular disease in recovered and deceased patients with COVID-19. We performed 3 additional meta-analyses of proportions to produce point estimates of the mortality and incidence of acute cerebrovascular disease in COVID-19 patients. Patient's with COVID-19 who died were 12.6 times more likely to have a history of cerebrovascular disease. We estimated an occurrence rate of 2.6% (95% confidence interval, 1.2-5.4%) for acute cerebrovascular disease among consecutively admitted patients with COVID-19. While for those with severe COVID-19' we estimated an occurrence rate of 6.5% (95% confidence interval, 4.4-9.6%). Our analysis estimated a rate of 35.5% for in-hospital mortality among COVID-19 patients with concomitant acute cerebrovascular disease. This was consistent with a mortality rate of 34.0% which we obtained through an individual patient analysis of 47 patients derived from all available case reports and case series. COVID-19 patients with either acute or chronic cerebrovascular disease have a high mortality rate with higher occurrence of cerebrovascular disease in patients with severe COVID-19.

Clinical and functional features and quality of life in depressive disorders in patients undergoing pulmonary thromboendarterectomy

Aim. To conduct a comparative analysis of clinical and functional parameters and quality of life (QoL) in patients with chronic thromboembolic pulmonary hypertension (CTEPH), depending on the presence of a depressive disorder in long-term postoperative period.Material and methods. The study included 182 patients with CTEPH in the long term after surgery. Depending on the Patient Health Questionnaire 9 ( PHQ-9) data, all patients were divided into 2 groups: the 1st group — patients without depressive syndrome in the long-term postoperative period, the 2nd — patients with depressive syndrome. A comparative assessment of the initial clinical and functional characteristics, as well as QoL was carried out using the SF-36 questionnaire in both groups of patients. In patients who had a coronavirus disease 2019 (COVID-19), a comparative assessment using the Post-COVID-19 Functional Status (PCFS) scale was carried out.Results. Clinically relevant depressive syndrome in patients with CTEPH in the long term after surgery was registered in 25,3% of cases. In the 2nd group of patients, prior myocardial infarction (p=0,02), concomitant chronic cerebrovascular disease (p=0,01), as well as moderate and severe post-COVID-19 functional limitations according to the PCFS scale (p=0,004) were significantly more often recorded compared with the 1st group. In the 2nd group of patients, the level of QoL in almost all parameters was significantly lower in comparison with the 1st group (p&lt;0,05). Decreased QoL (score &lt;40) in the 2nd group concerned numerous parameters, including the physical and mental health components. In the 1st group of patients, reduced QoL was observed only in some physical parameters.Conclusion. The group of patients with CTEPH with depressive syndrome in the long-term postoperative period was characterized by a higher incidence of concomitant chronic cerebrovascular disease and a history of myocardial infarction compared with patients without depressive disorders. In the group of patients with depressive disorders, moderate and severe post-COVID-19 functional limitations according to the PCFS scale were more often observed. Depressive disorders in patients with CTEPH in the long-term postoperative period were accompanied by significantly reduced QoL parameters. Patients experienced the greatest difficulties both during normal daily activities and in professional activities.

Influence of polyvascular disease on clinical outcome in patients undergoing transcatheter aortic valve implantation via transfemoral access.

BackgroundThe influence of polyvascular disease (PVD) on the short- and long-term clinical outcomes of patients undergoing transcatheter aortic valve implantation via trans-femoral access (TF-TAVI) has not been fully elucidated.MethodsA total of 2167 patients from the Optimized CathEter vAlvular iNtervention-TAVI (OCEAN-TAVI) registry who underwent TF-TAVI was studied. PVD was defined as the presence of at least two of the following vascular bed (VB) diseases: concomitant coronary artery disease (CAD), cerebrovascular disease (CVD), and peripheral artery disease (PAD).ResultsPatients with PVD (288 patients, 13.3%) had a higher incidence of in-hospital complications, such as AKI (16.3% vs. 7.0%, p<0.01) and disabling stroke (3.5% vs. 1.2%, p<0.01) than patients without PVD. These complications caused higher rates of procedural mortality (4.5% vs. 2.0%, p<0.01). PVD increased the risk of the 2-year rate of cardiovascular death (adjusted hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.04–2.50; p<0.05); however, non-cardiovascular death, myocardial infarction, or ischemic stroke was not associated with PVD. Worsening heart failure (4.6% vs. 1.1%, p<0.01) was the main cause of cardiovascular death among patients with PVD. In a sub-analysis, compared with patients with AS alone, those with 2 VB diseases (CAD+PAD; adjusted HR, 1.93; 95% CI, 1.06–3.53; p<0.05) and 3 VB diseases (CAD+CVD+PAD; adjusted HR, 2.61; 95% CI, 1.21–5.62; p<0.05) had a higher risk of 2-year cardiovascular death.ConclusionsThe increased prevalence of concomitant atherosclerotic VB diseases before TF-TAVI may increase the rates of in-hospital complications and 2-year cardiovascular death. Given the higher rate of mortality in patients with PVD undergoing TF-TAVI, future studies focusing on medical therapy are needed to reduce long-term cardiovascular events in this high-risk subset.

Plasma P-tau181 to Aβ42 ratio is associated with brain amyloid burden and hippocampal atrophy in an Asian cohort of Alzheimer's disease patients with concomitant cerebrovascular disease.

There is increasing evidence that phosphorylated tau (P-tau181) is a specific biomarker for Alzheimer's disease (AD) pathology, but its potential utility in non-White patient cohorts and patients with concomitant cerebrovascular disease (CeVD) is unknown. Single molecule array (Simoa) measurements of plasma P-tau181, total tau, amyloid beta (Aβ)40 and Aβ42, as well as derived ratios were correlated with neuroimaging modalities indicating brain amyloid (Aβ+), hippocampal atrophy, and CeVD in a Singapore-based cohort of non-cognitively impaired (NCI; n=43), cognitively impaired no dementia (CIND; n=91), AD (n=44), and vascular dementia (VaD; n=22) subjects. P-tau181/Aβ42 ratio showed the highest area under the curve (AUC) for Aβ+ (AUC=0.889) and for discriminating between AD Aβ+ and VaD Aβ- subjects (AUC=0.903). In addition, P-tau181/Aβ42 ratio was associated with hippocampal atrophy. None of the biomarkers was associated with CeVD. Plasma P-tau181/Aβ42 ratio may be a noninvasive means of identifying AD with elevated brain amyloid in populations with concomitant CeVD.

Lipid-Lowering Therapy in Patients with Coronary Heart Disease and Prior Stroke: Mission Impossible?

Hyperlipidemia is a powerful risk factor for coronary heart disease (CHD). It has been known for a long time that lipid-lowering drugs significantly reduce morbidity from CHD, thus proving a causal role for cholesterol in coronary events. Conversely, the relationship between low-density lipoprotein cholesterol (LDL-C) levels and stroke has been less clear and debated for many years. Recent data conclusively demonstrate not only the inverse epidemiological relationship of blood LDL-C with stroke, but also the efficacy of different strategies to attain cholesterol-lowering on stroke. They also dissipate lingering doubts about the possibility that lipid-lowering is linked to an increase in hemorrhagic stroke. However, despite current international lipid guidelines now strongly recommend aggressive lipid-lowering therapy in patients with atherosclerotic cardiovascular disease, including CHD and cerebrovascular disease (CeVD), secondary prevention patients are often undertreated with lipid-lowering therapies in routine clinical practice. This review highlights that patients with CHD and concomitant CeVD do not receive aggressive lipid-lowering therapy despite being at very high risk and with clear evidence of benefit from lowering LDL-C levels below current targets.

Selective Nonoperative and Delayed Management of Severe Asymptomatic Carotid Artery Stenosis

Although intervention is generally the standard of care for severe (80-99%) asymptomatic carotid stenosis, conservative management may be appropriate for a subset of patients. Our goal was to assess reasons for and outcomes of nonoperative/delayed operative management of asymptomatic severe carotid stenosis. Institutional vascular laboratory data from 2010 to 2018 was queried for all patients who underwent a carotid duplex ultrasonography. Patients with severe asymptomatic carotid stenosis (80-99%) were included. Such stenosis was defined by an end diastolic velocity >140cm/sec on duplex ultrasound in patients without transient ischemic attacks (TIA)/strokes ≤6months prior to imaging. Nonoperative/delayed operative management was defined as not undergone carotid endarterectomy (CEA) or carotid artery stent (CAS) ≤6months after imaging. Reasons for nonoperative management or delayed intervention as well as subsequent TIA/stroke and survival were determined. Kaplan-Meier analysis was performed to evaluate survival. Among 211 patients with severe carotid stenosis, 35 (16.6%) were managed nonoperatively or with delayed operation. Mean age in this subset was 72.6±11.4years and the majority were female (57.1%), had a smoking history (74.3%), and were on statins (91.4%) at the time of index duplex ultrasound. Reasons for no/delayed intervention were classified as severe medical comorbidities (37.1%), advanced age (17.1%), no referral for intervention (14.3%), patient refusal (14.3%), other severe concomitant cerebrovascular disease (11.4%), and active/advanced cancer (5.7%). Over a median follow-up of 35.2months, no patients experienced TIAs/strokes attributable to carotid stenosis. One patient had a multifocal bilateral stroke after a cardiac arrest and prolonged resuscitation. A subset of patients underwent delayed CEA (8.6%) or CAS (2.9%). Four-year survival after initial imaging was 79%. Reasons for nonoperative and delayed operative management in our cohort of asymptomatic carotid stenosis were commonly due to comorbidities and advanced age. However, a subset of patients was never referred to vascular surgeons/interventionalists. Adverse neurologic events due to carotid stenosis were not observed during follow-up and patients had relatively high long-term survival.

Risk Factors for Polyvascular Involvement in Patients With Peripheral Artery Disease: A Mendelian Randomization Study.

BackgroundAtherosclerosis in >1 vascular bed (ie, polyvascular disease), often a feature of peripheral artery disease (PAD), is associated with high morbidity and mortality. We sought to identify risk factors for polyvascular involvement in patients with PAD.Methods and ResultsWe performed 2‐sample Mendelian randomization using an inverse‐variance‐weighted approach, to assess 60 exposures including size and lipid content of atherogenic lipoproteins, blood pressure, glycated hemoglobin, and smoking as causal mediators for polyvascular disease in patients with PAD. Genetic instruments for these exposures were obtained from prior genome‐wide association studies. Patients with PAD were from the Mayo Vascular Disease Biorepository, and polyvascular disease (ie, concomitant coronary heart disease, cerebrovascular disease, and/or abdominal aortic aneurysm) was ascertained by validated phenotyping algorithms. Of 3279 patients with PAD, 61% had polyvascular disease. Genetically predicted levels of the lipid content and/or particle measures of very small and small size very low‐density lipoprotein, intermediate‐density lipoprotein, and large low‐density lipoprotein were associated with polyvascular disease: odds ratios (OR) of 1.80 (95% CI, 1.23–2.61), 1.70 (95% CI, 1.17–2.61), and 1.40 (95% CI, 1.09–1.80) per 1 SD increase in genetically determined levels, respectively. Both genetically predicted diastolic and systolic blood pressure were associated with polyvascular disease; OR per 10 mm Hg genetic increase in diastolic and systolic blood pressure were 1.66 (95% CI, 1.19–2.33) and 1.31 (95% CI, 1.07–1.60), respectively.ConclusionsLifetime exposure to increased lipid content and levels of very small and small very low‐density lipoprotein, intermediate‐density lipoprotein, and large low‐density lipoprotein particles as well as elevated blood pressure are associated with polyvascular involvement in patients with PAD. Reduction in levels of such exposures may limit progression of atherosclerosis in patients with PAD.

Considering the Feasibility, Tolerability, and Safety of High-Intensity Interval Training as a Novel Treatment for Patients With Intermittent Claudication.

This study assessed the feasibility, tolerability, safety, and potential efficacy of a novel, 6-wk, high-intensity interval training (HIIT) program for patients with intermittent claudication (IC). Patients referred to a usual-care supervised exercise program were invited to undertake a HIIT program. All recruited patients performed a baseline cardiopulmonary exercise test (CPX) to inform their exercise prescription. HIIT involved 10, 1-min high-intensity cycling intervals interspersed with 1-min recovery intervals, performed 3 d/wk for 6 wk. Outcomes included feasibility, tolerability, safety, walking distance, and quality of life. A total of 144 patients with IC were referred, 95 met initial eligibility criteria (66%) and 30 (32%) were recruited for HIIT, of which 15 (50%) completed. Of the recruited patients, 90% were on optimal medical therapy and 40% had concomitant cardiac, cerebrovascular, and/or respiratory disease. Patients who completed the program attended 100% of the sessions and one serious adverse event was recorded. Improvements in walking distances and quality of life were observed. Following recruitment of the first 20 patients, the inclusion criteria were refined on the basis of CPX, leading to improved completion rates. This study provides preliminary findings indicating that patients with IC can complete a short-term HIIT program. We provide very early evidence that HIIT may be safe and well-tolerated. In addition, walking distances seem to improve following HIIT. After a small change in the exclusion criteria, the intervention and inclusion/exclusion criteria now seem appropriate for this population, meaning further research to evaluate HIIT in patients with IC is warranted.

Association of treatments for acute myocardial infarction and survival for seven common comorbidity states: a nationwide cohort study

BackgroundComorbidity is common and has a substantial negative impact on the prognosis of patients with acute myocardial infarction (AMI). Whilst receipt of guideline-indicated treatment for AMI is associated with improved prognosis, the extent to which comorbidities influence treatment provision its efficacy is unknown. Therefore, we investigated the association between treatment provision for AMI and survival for seven common comorbidities.MethodsWe used data of 693,388 AMI patients recorded in the Myocardial Ischaemia National Audit Project (MINAP), 2003–2013. We investigated the association between comorbidities and receipt of optimal care for AMI (receipt of all eligible guideline-indicated treatments), and the effect of receipt of optimal care for comorbid AMI patients on long-term survival using flexible parametric survival models.ResultsA total of 412,809 [59.5%] patients with AMI had at least one comorbidity, including hypertension (302,388 [48.7%]), diabetes (122,228 [19.4%]), chronic obstructive pulmonary disease (COPD, 89,221 [14.9%]), cerebrovascular disease (51,883 [8.6%]), chronic heart failure (33,813 [5.6%]), chronic renal failure (31,029 [5.0%]) and peripheral vascular disease (27,627 [4.6%]).Receipt of optimal care was associated with greatest survival benefit for patients without comorbidities (HR 0.53, 95% CI 0.51–0.56) followed by patients with hypertension (HR 0.60, 95% CI 0.58–0.62), diabetes (HR 0.83, 95% CI 0.80–0.87), peripheral vascular disease (HR 0.85, 95% CI 0.79–0.91), renal failure (HR 0.89, 95% CI 0.84–0.94) and COPD (HR 0.90, 95% CI 0.87–0.94). For patients with heart failure and cerebrovascular disease, optimal care for AMI was not associated with improved survival.ConclusionsOverall, guideline-indicated care was associated with improved long-term survival. However, this was not the case in AMI patients with concomitant heart failure or cerebrovascular disease. There is therefore a need for novel treatments to improve outcomes for AMI patients with pre-existing heart failure or cerebrovascular disease.

Undiagnosed Dementia in Patients with Peripheral Arterial Disease: A Systematic Review of the Literature

Objective: It is purported that patients with peripheral arterial disease (PAD) may have impaired cognitive function due to concomitant cerebrovascular disease. Such disease may be clinically unrecognised but can impact on a patient’s recovery and prognosis. The purpose of this systematic review was to interrogate the body of published evidence on undiagnosed dementia in PAD patients. Methods: A search strategy encompassing MEDLINE, Scopus, and the Cochrane database was developed to identify peer reviewed articles examining rates of undiagnosed dementia in patients with PAD. The following search terms were used: “PAD”; “PVD”; “dementia”; “peripheral arterial disease”; “peripheral vascular disease”; “cognitive impairment”; “Alzheimer’s disease”, and “cogniti”. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 guidelines were followed throughout. The primary outcome was the incidence of previously undiagnosed dementia in patients with PAD. Results: The initial electronic literature search yielded 1 492 titles. After removal of duplicates, 994 abstracts were screened in order to ascertain if they were potentially eligible for inclusion. Abstract review yielded 62 full texts for further evaluation, and from this eight case–control studies consisting of 1 161 patients were included in the review. Analysis of these studies revealed that PAD patients performed significantly worse than controls on a variety of neuropsychological measures of executive function (six out of eight studies). Conclusion: The review indicated that PAD patients are more likely to have undiagnosed dementia than healthy controls. This condition may impact on their ability to comply with treatment strategies and should be borne in mind when managing this challenging patient cohort.

Heart-brain interactions

Heart-brain interactions are represented by the association of cerebral ischemia with coronary artery disease, cardioembolic cerebral ischemia, and cardiovascular complications due to brain damage. As atherosclerosis is a systemic inflammatory disease, in patients with transient ischemic attack, stroke or asymptomatic carotid artery disease, a previous myocardial infarction, angina or an asymptomatic coronary artery disease are often associated and a correlation between the carotid atherosclerosis and coronary artery disease severity has been reported. Furthermore, the long-term prognosis of patients with stroke is strongly affected by coronary events. At the same time, the prevalence of concomitant cerebrovascular disease is common in patients with coronary artery disease. Other cardiovascular diseases, including left atrial and left atrial appendage thrombosis in atrial fibrillation, thrombi in the left ventricle in acute and chronic coronary artery disease and dilated cardiomyopathies, infective endocarditis with vegetations, cardiac valve prosthesis thrombosis, cardiac tumors, mitral and aortic valve calcifications, aortic plaques and patent foramen ovale, are associated with cardioembolic events. Finally, acute ischemic or hemorrhagic cerebral events, epileptic seizures, cerebral traumas, and brain tumors can be associated with electrocardiographic abnormalities, catecholaminergic myocardial damage, or arrhythmias.

Multiple infarcts and hemorrhages in the central nervous system of a dog with cerebral amyloid angiopathy: a case report

Backgroundβ-amyloid (Aβ) can accumulate in the brain of aged dogs, and within vessels walls, the disease is called cerebral amyloid angiopathy (CAA). In humans, Alzheimer’s disease and CAA are strongly correlated with cerebrovascular disease. However, in dogs, this association has not been extensively studied yet. The present report highlights the pathological and clinical features of a concomitant cerebrovascular disease and amyloid precursor protein (APP) accumulation in the brain of a dog.Case presentationA female, 16-year-old, Standard Poodle with a one-year history of cognitive deficits presented with an acute onset of right-sided postural reaction deficit and circling, left-sided head tilt, positional nystagmus, and ataxia. Due to poor prognosis the dog was euthanized, and pathological examination of the brain revealed an acute lacunar infarction within the thalamus extending to rostral colliculus. Additional findings included subacute and chronic areas of ischemia throughout the brain and areas of hemorrhage within the medulla. Immunolabeling revealed APP deposition within intraparenchymal vessels of frontal, temporal and occipital cortex, hippocampus, diencephalon, mesencephalon and myelencephalon, besides meningeal vessels walls. Glial fibrillary acidic protein (GFAP) immunolabeling showed marked astrocytosis around the acute area of infarction and within chronic areas of ischemia. Histological examination of the brain along with immunohistochemistry results showed a concomitant APP, which is an Aβ precursor, accumulation within the neuroparenchyma and vessels (CAA) with histological evidences of a cerebrovascular disease in an aged dog.ConclusionsThis report shows that APP accumulation in the brain can occur concomitantly to a severe cerebrovascular disease in a dog. Further studies are necessary to elucidate if cerebrovascular disease is associated with Aβ accumulation in the brain of dogs.

Platelet count is associated with outcome in cancer patients with stroke.

Cerebrovascular disease (CVD) and cancer are among the most common causes of mortality worldwide, preceded only by ischemic heart disease (IHD). Thrombocytopenia was shown to be associated with poor outcomes in IHD and CVD in the general population. This study aimed to assess the relationship of thrombocytopenia with poor outcomes in cancer patients with CVD. Data on patients with concomitant CVD and cancer who were initially treated at a cancer referral center between January 2010 and December 2017 were included. Thrombocytopenia was defined as a platelet count < 150,000/mm3 during the first 24h of CVD symptom onset. The IRB (CI/837/17) approved the review of clinical records. Among 268 cancer patients with CVD included in the study, 210 met the inclusion criteria. Median overall survival of the entire cohort was 7.2 months, which was significantly shorter in males (p = 0.029) and patients with hematologic tumors (p = 0.009), hemorrhagic CVD (p < 0.001), altered mental status (p < 0.001), and thrombocytopenia (p < 0.001). Multiple regression logistic analysis revealed that thrombocytopenia (risk ratio [RR] 1.6, 95% confidence interval [CI] 1.1-2.4) and altered mental status (RR 2.7, 95% CI 1.9-4.0) remained statistically significant risk factors for mortality. In cancer patients with CVD, thrombocytopenia at the time of CVD diagnosis and altered mental status during initial clinical evaluation were associated with higher mortality, which should be confirmed in future studies.

Cardiovascular risk reduction in referrals to outpatient vascular clinics

Introduction Patients with peripheral arterial disease (PAD), aneurysmal disease (AD) or carotid atherosclerosis are at high cardiovascular risk, necessitating secondary cardiovascular protection. The aim of this study was to determine compliance with cardiovascular risk reduction guidelines in new patients referred to vascular clinics. Methods A multicentre collaborative national observational audit of new patients referred to eight tertiary general vascular clinics over a three-month period in England and Wales was conducted by the Vascular and Endovascular Research Network (VERN). Referral letters, case notes and investigations were reviewed by local investigators, and data analysed by VERN. Results A total of 656 patients were included in the study: 73.2% had PAD, 23.2% had AD and 3.7% had carotid atherosclerosis. A third (37.5%) were current smokers, two-thirds (61.7%) were on antiplatelet therapy and two-thirds (61.5%) were on statin therapy. Smoking was more prevalent in the PAD cohort (PAD 41.4%, AD 27.5%, p=0.003). However, more PAD patients were on antiplatelet therapy (PAD 63.9%, AD 53.3%, p=0.024). Both antiplatelet and statin prescription significantly increased with the number of cardiovascular risk factors. Patients with a previous cardiac or cerebrovascular history were more likely to have stopped smoking, and to be on antiplatelet and statin therapy (p&lt;0.0001 for each). Overall, 47.3% of patients were on both antiplatelet and statin therapy, and 28.9% were on antiplatelet and statin therapy and not smoking. Conclusions This study highlights deficiencies in cardiovascular risk minimisation in patients with established vascular disease. Patients with concomitant cardiac or cerebrovascular disease were more likely to be on best medical therapy.

ФАКТОРЫ РИСКА КОГНИТИВНЫХ НАРУШЕНИЙ ПРИ БОЛЕЗНИ ПАРКИНСОНА И ДИСЦИРКУЛЯТОРНОЙ ЭНЦЕФАЛОПАТИИ

The aim of the study was to examine the state of cognitive functions in patients with Parkinson's disease combined with the dyscirculatory encephalopathy and identify their risk factors for cognitive impairment. The results of the study showed that the frequency of cognitive impairment in patients with Parkinson's disease combined with the dyscirculatory encephalopathy was 90.3 %, Parkinson's disease without brain vascular disease - 28.6 %. Patients with concomitant cerebrovascular disease had more severe frontal deficit (mean score on the FAB in the main group -14.86 ± 2.18, in the control -16.93 ± 2.21; p < 0.0001), which manifested itself in the form of difficulty when performing tests for dynamic movements, simple and complicated reactions of choice, had the worst performance of speech and general mental activity, attention. In order to assess the relationship of certain clinical, social and biological factors with indicators of cognitive functions we conducted Spearman rank correlation analysis. Risk factors for the development of cognitive impairment of Parkinson's disease combined with vascular encephalopathy were age of patients, severity of motor impairment, duration and severity of hypertension, coronary heart disease, and the presence of acute cardiovascular events in history.

Distinct white matter microstructural abnormalities and extracellular water increases relate to cognitive impairment in Alzheimer\u2019s disease with and without cerebrovascular disease

BackgroundMixed vascular and neurodegenerative dementia, such as Alzheimer’s disease (AD) with concomitant cerebrovascular disease, has emerged as the leading cause of age-related cognitive impairment. The brain white matter (WM) microstructural changes in neurodegeneration well-documented by diffusion tensor imaging (DTI) can originate from brain tissue or extracellular free water changes. The differential microstructural and free water changes in AD with and without cerebrovascular disease, especially in normal-appearing WM, remain largely unknown. To cover these gaps, we aimed to characterize the WM free water and tissue microstructural changes in AD and mixed dementia as well as their associations with cognition using a novel free water imaging method.MethodsWe compared WM free water and free water-corrected DTI measures as well as white matter hyperintensity (WMH) in patients with AD with and without cerebrovascular disease, patients with vascular dementia, and age-matched healthy control subjects.ResultsThe cerebrovascular disease groups had higher free water than the non-cerebrovascular disease groups. Importantly, besides the cerebrovascular disease groups, patients with AD without cerebrovascular disease also had increased free water in normal-appearing WM compared with healthy control subjects, reflecting mild vascular damage. Such free water increases in WM or normal-appearing WM (but not WMH) contributed to dementia severity. Whole-brain voxel-wise analysis revealed a close association between widespread free water increases and poorer attention, executive functioning, visual construction, and motor performance, whereas only left hemispheric free water increases were related to language deficits. Moreover, compared with the original DTI metrics, the free water-corrected DTI metric revealed tissue damage-specific (frontal and occipital) microstructural differences between the cerebrovascular disease and non-cerebrovascular disease groups. In contrast to both lobar and subcortical/brainstem free water increases, only focal lobar microstructural damage was associated with poorer cognitive performance.ConclusionsOur findings suggest that free water analysis isolates probable mild vascular damage from WM microstructural alterations and underscore the importance of normal-appearing WM changes underlying cognitive and functional impairment in AD with and without cerebrovascular disease. Further developed, the combined free water and tissue neuroimaging assays could help in differential diagnosis, treatment planning, and disease monitoring of patients with mixed dementia.

Impact of multiple pathologies on the threshold for clinically overt dementia.

Longitudinal clinical-pathological studies have increasingly recognized the importance of mixed pathologies (the coexistence of one or more neurodegenerative and cerebrovascular disease pathologies) as important factors in the development ofAlzheimer's disease (AD) and other forms of dementia. Older persons with AD pathology, often have concomitant cerebrovascular disease pathologies (macroinfarcts, microinfarcts, atherosclerosis, arteriolosclerosis, cerebral amyloid angiopathy) as well as other concomitant neurodegenerative disease pathologies (Lewy bodies, TDP-43, hippocampal sclerosis). These additional pathologies lower the threshold for clinical diagnosis of AD. Many of these findings from pathologic studies, especially for CVD, have been confirmed using sophisticated neuroimaging technologies. In vivo biomarker studies are necessary to provide an understanding of specific pathologic contributions and time course relationships along the spectrum of accumulating pathologies. In this review, we provide a clinical-pathological perspective on the role of multiple brain pathologies in dementia followed by a review of the available clinical and biomarker data on some of the mixed pathologies.