Evidence Of Stroke Research Articles

Reversible Cerebral Vasoconstriction Syndrome with Subarachnoid Hemorrhage and Stroke

AbstractReversible cerebral vasoconstriction syndrome is a complex condition characterized by temporary constriction of the brain's arteries. Diagnosis typically involves a retrospective approach, necessitating repeated imaging to confirm the resolution of cerebral arterial spasms. We describe a case of a 22-year-old female with a history of posterior circulation stroke and recurrent thunderclap headaches. On imaging, evidence of stroke, convexity subarachnoid hemorrhage, and multiple areas of stenosis and dilatation in the posterior circulation associated with normal laboratory parameters were found. The resolution of clinical symptoms and angiographic findings were noted in the follow-up. After other diagnoses are excluded, patients can be reassured about favorable prognosis.

Evidence of Stroke in Glaucoma Patients

Background As the communal cause of irreversible vision loss in seniors, glaucoma affects more than 67 million people worldwide. Those who suffer from glaucoma have traditionally demonstrated a higher rate of developing stroke. Numerous studies have investigated the relationship between glaucoma and increased stroke risks, but they differ wildly in conclusive findings. To better elucidate the overall findings of the collective studies, a systematic review with the objective of determining the relationship between glaucoma and an increased risk of stroke. Methods A systematic database search including MEDLINE, EMBASE, and Cochrane Library as well as unpublished literature was done. Distiller SR, a systematic review software was utilized. After two levels of screening, “Title and Abstract” and “Full text” screening, risk of bias assessment and extraction of the data from the included articles were conducted. STATA 14.0 was used to conduct the meta-analysis. The hazard ratio (HR) was the primary outcome measure. Results Nine studies (376,650 subjects) were included in the analysis. Results indicated a significant hazard of stroke in patients with open-angle glaucoma (HR = 1.36, 95% confidence interval [CI]: [1.08, 1.71]), normal-tension glaucoma (HR = 6.34, 95% CI: [4.8, 8.38]), and neovascular glaucoma (HR = 2.07; CI: [1.41, 3.03]). Studies examining risks of stroke development showed a significant increase in the relative risks (RR) of developing stroke for those with glaucoma (RR = 2.10, CI: [1.64, 2.68]). Conclusions The hazard of developing stroke could be greater for patients with glaucoma. However, randomized controlled trials with longer-term follow-ups need to be conducted in the future in order to make strong conclusions.

Abstract 098: Symphony of Risk: A Case Report of Carotid Artery Dissection Associated with Violin Playing

Introduction Carotid artery dissection (CAD) is an uncommon and potentially life‐threatening condition that can have a delayed presentation. More commonly associated with blunt cervical trauma, CAD due to repetitive stress to the neck goes under‐recognized, making it challenging to diagnose. Herein, we aim to shed light on a unique instance of CAD after continuous microtrauma, as well as highlight diagnostic challenges associated with CAD. Methods We present a case of a 57‐year‐old man who presented with a one‐week course of unequal pupils, left‐sided headaches, left sided ptosis, and intermittent blurry vision. Exam revealed a callous where he held a violin against his left neck, having endorsed playing for several years with repeated contortion of his head to the left (Figure 1A). Magnetic resonance angiogram (MRA) of the head and neck revealed an acute dissection of the left internal carotid artery (ICA) (Figure 1B). A diagnosis of Horner’s syndrome secondary to acute dissection of the left cervical ICA was made. Consent to share this information was obtained from the patient and witnessed by another physician. Results MRA head and neck showed a 2.5 cm irregularity of the distal left ICA with high signal on fat saturated T1‐weighted images consistent with an acute dissection (Figure 1B). The patient underwent an apraclonidine test and was positive for left sided Horner’s syndrome with reversal of anisocoria after application of drops (Figure 1C). Given no evidence of stroke or thrombus on imaging, he was placed on dual antiplatelet therapy (DAPT) for three months. He was advised not to play violin for a month and to restart cautiously with a pad between his neck and the instrument. Follow‐up imaging showed eventual resolution of the CAD, while physical exam revealed improvement in ptosis and miosis. Conclusion While playing the violin involves repetitive stress on the neck, there is limited research on this specific activity as a cause of carotid artery dissection, making it a rare occurrence. Common clinical manifestations of CAD include neck pain, headache, Horner’s syndrome, tinnitus, stroke, and lower cranial nerve palsies, occurring suddenly or over time. Diagnosing CAD typically involves a combination of thorough history, physical examination, and diagnostic imaging. Ongoing research in the optimal management of CAD focuses on minimizing the risk of stroke, after factoring in variables such as location of dissection and whether it is symptomatic or not.

Morning glory disc anomaly and its implications in moyamoya arteriopathy: a retrospective case series.

Morning glory disc anomaly (MGDA), a congenital abnormality of the optic nerve, may be associated with moyamoya arteriopathy, a cerebrovascular abnormality. In this study, the authors aimed to define the temporal evolution of cerebrovascular arteriopathy in patients with MGDA to characterize a rational strategy for screening and management over time. The records of pediatric neurosurgical patients at two academic institutions were retrospectively reviewed to identify cases of cerebral arteriopathy and MGDA, including radiographic and clinical records documenting patient outcomes of medical and surgical management. Thirteen cases of moyamoya syndrome (MMS) associated with MGDA were identified in 13 children aged 0.6-17 years. The pattern of arteriopathy resembled that of non-MGDA MMS, with predominantly anterior circulation involvement. The arteriopathy lateralized with the MGDA, although 3 patients also had contralateral involvement. The overall group was followed for a median of 3.2 years. Radiological biomarkers of cerebral ischemia were applied to guide surgical decisions, and more than half of the patients (7 of 13) had evidence of stroke or progression on serial imaging. Nine patients underwent revascularization surgery, and 4 were managed medically. Cerebral arteriopathy observed in association with MGDA resembles MMS seen in patients without MGDA and is dynamic, with progression observed over months to years and an associated risk of cerebral ischemia that indicates a role for surgical revascularization. Radiological biomarkers may augment clinical data to identify candidates for revascularization surgery.

Brain Tsunamis in Human High-Grade Glioma: Preliminary Observations.

Gliomas make up nearly 40% of all central nervous system tumors, with over 50% of those being high-grade gliomas. Emerging data suggests that electrophysiologic events in the peri-tumoral region may play a role in the behavior and progression of high-grade gliomas. While seizures in the peri-tumoral zone are well described, much larger and slowly propagating waves of spreading depolarization (SD) may potentially have roles in both non-epileptic transient neurologic deficits and tumor progression. SD has only recently been observed in pre-clinical glioma models and it is not known whether these events occur clinically. We present a case of SD occurring in a human high-grade glioma using gold-standard subdural DC ECoG recordings. This finding could have meaningful implications for both clinical symptomatology and potentially for disease progression in these patients. Our observations and hypotheses are based on analogy with a large body of evidence in stroke and acute neurological injury that have recently established SD as cause of transient neurological deficits as well as a fundamental mechanism of ischemic expansion. Whether SD could represent a mechanistic target in this process to limit such progression is a high priority for further clinical investigations.

Dual Antiplatelet Regimens for Transcatheter Aortic Valve Replacement and Corresponding Cardiac CT Evaluation of the Leaflets: Single-center Experience

Background: Transcatheter aortic valve replacement (TAVR) is a globally established therapy. However, there is significant variability in the antithrombotic management post-procedure. The data on antiplatetet and direct antithrombin agents suggest antiplatelet agents suffice. The degree of leaflet thickening on cardiac CT and the clinical implications of this finding remain poorly understood. Here, the authors aim to examine a low-risk cohort treated with dual antiplatelet therapy and the corresponding cardiac CT and clinical findings. Methods: This is a descriptive single center study examining patients who received dual antiplatelet therapy post-TAVR from 2017 to 2019. Patients underwent clinical, echocardiographic and cardiac CT follow up. Signs and symptoms of ischemic stroke, valve function, gradient, and cardiac CT findings of hypo-attenuated leaflet thickening and reduced leaflet mobility were recorded for all those who completed 6 months of follow-up. The study was registered and approved by the Ethics Committee. Results: A total of 116 patients were included. Hypo-attenuated leaflet thickening was detected in 11 patients. Only one had accompanying reduced leaflet mobility and an increase in gradient. This patient did not have any evidence of stroke or valve dysfunction. After switching to rivaroxaban, the gradient improved and a repeat cardiac CT demonstrated resolution of the leaflet thickening. Conclusion: This study illustrates the utility of cardiac CT in detecting leaflet thickening and restricted mobility post-TAVR in low-risk individuals treated with dual antiplatelet therapy. However, its role in guiding antithrombotic regimens cannot be ascertained from this study and additional larger scale studies comparing different regimens in both symptomatic and asymptomatic patients are necessary. Trial Registration: N/A.

Duration of hypertension and prevalence of end-organ damage in hypertensive patients

The objective of this study is to determine the prevalence of end-organ damage in hypertensive patients in a tertiary care hospital in Azad Kashmir. The study was conducted in a public sector teaching hospital of AJK-Medical College between March 2019 and Feb 2020. Adult hypertensive patients above the age of 27 years were included in the study from out-patient and in-patient departments. A standard Performa was used to collect and document the demographic information, medical history and physical examination of patients. The age, sex, residential area, marital status, education, profession, presenting complaints, smoking, addictions, functional status, and physical activity were recorded. The measurement of Blood Pressure (BP) was performed with a mercury sphygmomanometer and end-organs damage (Retinopathy, Nephropathy, Cardiovascular and cerebrovascular disease) was assessed by clinical evaluation and relevant investigations. A total of 100, hypertensive patients were enrolled in the study between the ages of 27 to 96 years. The mean age of the participants was 57 years (Std. deviation 17.8). 55% of patients were male while 45% of patients were female. 23% had good control of hypertension while 77% had poor control. 7% of participants were monitoring their BP on daily basis, 32% weekly, 39% once a month while 22% never had any schedule of monitoring their Blood Pressure. A family history of hypertension was present in 61%. Overall, 91% of the participants had retinopathy, 48% had nephropathy, 48% had cardiovascular disease and 19% had evidence of stroke. In conclusion, there is a high prevalence of End-Organ damage in middle age and elderly hypertensive patients. Keywords: Hypertension, hypertensive end-organ damage.

Abstract 13202: The Accuracy Of EMS Dispatch For Stroke Following The Introduction Of The Stroke Diagnostic Tool

Introduction: Early identification of stroke in the emergency call is key to timely reperfusion therapy. The Medical Priority Dispatch System (MPDS) is widely used and recent versions include a Stroke Diagnostic Tool (SDxT) using the FAST (Face, Arm, Speech) assessments. We conducted a retrospective observational study to examine whether introduction of the SDxT improved the identification of stroke/TIA in the emergency call in Victoria, Australia. Methods: We included all stroke dispatches (MPDS Code 28) for adults (aged ≥20 years) between 2008 and 2015. We linked this data to diagnoses from Ambulance Victoria, and the Victorian Department of Health and Human Services’ databases: the Victorian Emergency Minimum Dataset and the Victorian Admitted Episode Database. We examined the use of SDxT codes, and compared the proportion of stroke/TIA diagnoses before and after the introduction of the SDxT in September 2013. Results: Over the study period there were 108,917 Code 28 cases (average 13,600/year), 80% (n=86,906) were transported to an ED and 55% (n=60,334) were admitted to hospital. There were 3,141 diagnoses among the Code 28 cases, with 30% diagnosed with stroke/TIA. No changes was seen in the proportion of stroke/TIAs after the introduction of the SDxT (28.5% vs. 28.2%, p=0.23). The SDxT was used and complete in 63% (n=20,070) of calls. Patients with evidence of stroke on the SDxT were more likely to have stroke/TIA (partial evidence=29%, strong evidence=38% and clear evidence=40%) compared to those with no evidence (20%) and those with no/incomplete SDT (25%). Conclusions: Our results suggest a large proportion of stroke dispatches are not stroke/TIA, but evidence of stroke on the SDxT does identify marginally higher proportions. Further research is required to understand use of the tool, and public education on stroke assessments may be needed to realise its full potential.

Unusually High Prevalence of Stroke and Cerebral Vasculopathy in Hemoglobin SC Disease: A Retrospective Single Institution Study

Introduction: Unlike homozygous hemoglobin SS (HbSS) disease, stroke is a rare complication in hemoglobin SC (HbSC) disease. However, recent studies have demonstrated a high prevalence of silent stroke in HbSC disease. The factors associated with stroke and cerebral vasculopathy in the HbSC population are unknown. Methods: We conducted a retrospective study of all patients with sickle cell disease treated at the University of Missouri, Columbia, over an 18-year period (2000–2018). The goal of the study was to characterize the silent, overt stroke, and cerebral vasculopathy in HbSC patients and compare them to patients with HbSS and HbS/β thalassemia1 (thal) in this cohort. We also analyzed the laboratory and clinical factors associated with stroke and cerebral vasculopathy in the HbSC population. Results: Of the 34 HbSC individuals, we found that the overall prevalence of stroke and cerebral vasculopathy was 17.7%. Only females had evidence of stroke or cerebral vasculopathy in our HbSC cohort (33.3%, p = 0.019). Time-averaged means of maximum velocities were lower in the HbSC group than the HbSS group and did not correlate with stroke outcome. Among HbSC individuals, those with stroke and cerebral vasculopathy had a marginally higher serum creatinine than those without these complications (0.77 mg/dL vs. 0.88 mg/dL, p = 0.08). Stroke outcome was associated with recurrent vaso-occlusive pain crises (Rec VOCs) (75 vs. 25%, p = 0.003) in HbSC patients. The predominant cerebrovascular lesions in HbSC included microhemorrhages and leukoencephalopathy. Conclusion: There is a distinct subset of individuals with HbSC who developed overt, silent stroke, and cerebral vasculopathy. A female predominance and association with Rec VOCs were identified in our cohort; however, larger clinical trials are needed to identify and confirm specific clinical and laboratory markers associated with stroke and vasculopathy in HbSC disease.

Cerebral Bypass for Aneurysms in the Era of Flow Diversion: Single-Surgeon Case Series.

With recent advances in endovascular treatments of brain aneurysms such as flow diverters, the role of cerebral revascularization needs to be re-evaluated. To evaluate the contemporary indications and outcomes of cerebral revascularization for brain aneurysms. A retrospective evaluation of a prospectively maintained database was performed to review clinical and imaging data of all the patients who underwent cerebral revascularization for brain aneurysms over the past 10 yr. Among 174 cerebral revascularizations, 40 (in 36 patients) were done for the treatment of aneurysms. In total, 9 patients underwent combined endovascular treatment and surgical revascularization. Immediate aneurysm occlusion was achieved in 30 patients (83.3%). Immediate postoperative bypass patency was confirmed in 33 patients (92%). Postoperative neurological deficit was observed in 4 patients (11.1%). There were 2 mortalities in the postoperative period. Aneurysm total occlusion rate was 91% at 1 yr. Thirty patients had 1 yr clinical and radiological follow-up. Clinical evaluations showed modified Rankin Scale 2 or less in 25 patients at 1 yr. Bypass patency was confirmed in 27 (90%). Patients with fair/poor outcome were all in the subarachnoid hemorrhage group. Twenty-one patients had follow-up studies for 3 yr or beyond with no evidence of stroke or aneurysm recurrence. Our results support that cerebral revascularization can be regarded as a viable and durable treatment option for these challenging aneurysms with acceptable morbidity. Cerebral bypass should be offered in selected cases where standard endovascular or surgical treatment is not efficacious or curative.

Risk factors for ischemic stroke in children with tuberculous meningitis.

Cerebrovascular complications are commonly observed in children with tuberculous meningitis. We aimed to determine which clinical factors were associated with stroke at admission in children with tuberculous meningitis and, in children stroke-free at admission, which factors were associated with development of stroke on treatment. We analysed a cohort of 474 children diagnosed with 'definite' and 'probable' tuberculous meningitis, with prospectively collected data, at Tygerberg Hospital, Cape Town, South Africa from 1985 to 2005. We considered either hemiparesis or radiological arterial ischemic infarction as evidence of stroke. At admission, 339 (71.5%) children presented with stroke. Features associated with stroke at admission included age <3 years (odds ratio (OR) 3.70; 95% confidence interval (CI): 2.44-5.63; p < 0.01), convulsions (OR: 2.25; 95% CI: 1.46-3.45; p < 0.01) and hydrocephalus (OR: 1.63; 95% CI: 1.05-2.53; p = 0.03). In the group of children without stroke at admission (n = 135), 33 (24.4%) developed stroke by 1 month. Similar factors predicted stroke and included age <3 years (OR: 2.60; 95% CI: 1.17-5.80; p = 0.02), convulsions (OR: 2.25; 95% CI: 1.46-3.45; p < 0.01), CSF cell count <10 or >500/L (OR: 3.12; 95% CI: 1.03-9.43; p = 0.04) and hydrocephalus (OR: 2.99; 95% CI: 1.30-6.89; p = 0.01). A large proportion of children with tuberculous meningitis present with stroke at admission. Of those with no evidence of stroke at admission, a quarter develop stroke by 1 month, suggesting that there could be a brief window in which to give preventive therapy.

When is extra-anatomical bypass for the left subclavian artery required to prevent ischaemia after thoracic endovascular stent grafting?

Thoracic endovascular aortic repair (TEVAR) has become an accepted treatment for thoracic aortic disease. However, the principal complications relate to coverage of the thoracic aortic wall and deliberate occlusion of aortic branches over a potentially long segment. Complications include risk of stroke, spinal cord ischaemia (SCI) and arterial insufficiency to the left arm (left arm ischaemia (LAI)). This study specifically scrutinised the development of SCI and LAI after TEVAR for interventions for thoracic aortic disease from 1999 to 2020. In particular, those who underwent extra-anatomical bypass (both immediate and late) were compared to the length of thoracic aortic coverage by the stent graft. Ninety-eight patients underwent TEVAR. The presenting symptoms, pathology, procedural and follow-up data were collected prospectively with particular evidence of stroke, SCI and LAI both immediate onset and after 48 h of graft placement. Fifty underwent TEVAR for an aneurysm (thoracoabdominal aortic aneurysm), 22 for dissection, 19 for acute transection and 7 for intramural haematoma/pseudoaneurysm of the thoracic aorta. Twenty-nine (30%) required a debranching procedure to increase the proximal landing zone (1 aorto-carotid subclavian bypass, 10 carotid/carotid subclavian bypass and 18 carotid/subclavian bypass). Ten patients (10%) died within 30 days of TEVAR. Twenty-four grafts covered the left subclavian artery origin without a carotid/subclavian bypass. Five required a delayed carotid/subclavian bypass for LAI (4) and SCI (1). Six developed immediate signs of SCI after TEVAR and these 11 (group i) had a mean (SD) length of coverage of the thoracic aorta of 30.2 (10.6) cm compared to 21.5 (11.2) cm (group g) in those who had no LAI or SCI post TEVAR, p < 0.05. In this series, delayed carotid/subclavian bypass may be required for chronic arm ischaemia and less so for SCI. The length of coverage of thoracic aorta during TEVAR is a factor in the development of delayed SCI and LAI occurrence. Carotid subclavian bypass is required for certain patients undergoing TEVAR (particularly if greater than 20 cm of thoracic aorta is covered).

Stroke Thrombolysis in Patients Taking Ticagrelor –Two Successful Cases and a Review of the Literature

BackgroundTicagrelor is a novel antiplatelet agent that is frequently used for secondary prevention in coronary artery disease and has emerging evidence in stroke after the recent results of SOCRATES and THALES trials. The use of intravenous thrombolysis with alteplase in acute ischemic stroke (AIS) patients on ticagrelor is a topic of debate as the safety profile of ticagrelor in this setting is not well established. MethodsWe identified consecutive AIS patients taking ticagrelor who received intravenous alteplase at a comprehensive stroke center from January 2016 to December 2019. We then performed a literature search to capture all known published cases of intravenous thrombolysis in stroke patients on ticagrelor. ResultsOf the 3896 patients who were treated for AIS at our local comprehensive stroke center during this time period, two patients received intravenous alteplase while on ticagrelor. Both patients had posterior circulation acute strokes and were successfully treated with intravenous alteplase without a systemic or intracranial bleeding event. Only five other cases of intravenous thrombolysis in AIS patients on ticagrelor have been reported in the literature. Among these cases, four of the five cases had a hemorrhagic complication. ConclusionDespite prior reports of hemorrhagic complications with use of IV alteplase in setting of pre-treatment with ticagrelor, we report the safe use of intravenous thrombolysis in two cases presenting with acute ischemic stroke. Until safety is established in large studies, decision for thrombolysis should be made on case-by-case basis.

Pilot randomised clinical trial of an eHealth, self-management support intervention (iVERVE) for stroke: feasibility assessment in survivors\xa012\u201324 months post-event

BackgroundElectronic communication is used in various populations to achieve health goals, but evidence in stroke is lacking. We pilot tested the feasibility and potential effectiveness of a novel personalised electronic self-management intervention to support person-centred goal attainment and secondary prevention after stroke.MethodsA phase I, prospective, randomised controlled pilot trial (1:1 allocation) with assessor blinding, intention-to-treat analysis, and a process evaluation. Community-based survivors of stroke were recruited from participants in the Australian Stroke Clinical Registry (AuSCR) who had indicated their willingness to be contacted for research studies. Inclusion criteria include 1–2 years following hospital admission for stroke and living within 50 km of Monash University (Melbourne). Person-centred goals were set with facilitation by a clinician using a standardised template. The intervention group received electronic support messages aligned to their goals over 4 weeks. The control group received only 2–3 electronic administrative messages. Primary outcomes were study retention, goal attainment (assessed using Goal Attainment Scaling method) and satisfaction. Secondary outcomes were self-management (Health Education Impact Questionnaire: 8 domains), quality of life, mood and acceptability.ResultsOf 340 invitations sent from AuSCR, 73 responded, 68 were eligible and 57 (84%) completed the baseline assessment. At the goal-setting stage, 54/68 (79%) were randomised (median 16 months after stroke): 25 to intervention (median age 69 years; 40% female) and 29 to control (median age 68 years; 38% female). Forty-five (83%) participants completed the outcome follow-up assessment. At follow-up, goal attainment (mean GAS-T score ≥ 50) in the intervention group was achieved for goals related to function, participation and environment (control: environment only). Most intervention participants provided positive feedback and reported that the iVERVE messages were easy to understand (92%) and assisted them in achieving their goals (77%). We found preliminary evidence of non-significant improvements between the groups for most self-management domains (e.g. social integration and support: β coefficient 0.34; 95% CI − 0.14 to 0.83) and several quality-of-life domains in favour of the intervention group.ConclusionThese findings support the need for further randomised effectiveness trials of the iVERVE program to be tested in people with new stroke.Trial registrationANZCTR, ACTRN12618001519246. Registered on 11 September 2018—retrospectively registered.

Posterior Internal Frontal Artery Vascularization of the Precentral Gyrus Responsible for Proximal Arm Movement: Insight from a Case of Coil Migration

Our knowledge of the vascularization of the precentral gyrus by branches of the anterior cerebral artery (ACA) relies mainly on anatomical cadaveric dissection. A distal branch of the ACA known as the posterior internal frontal artery (PIFA) is thought to vascularize the precentral gyrus responsible for proximal arm movement; however, no clinical correlation has yet been reported to confirm this relation. In this manuscript, we report a case of coil migration in the PIFA, causing proximal arm weakness in a 58-year-old woman treated for aneurysmal subarachnoid hemorrhage. The occurrence of clinical signs immediately following coil migration into the PIFA, combined with evidence of stroke in the cortical territory related to arm movement as seen on imaging, indicates that the PIFA indeed can vascularize this lateral portion of the precentral gyrus. This case confirms our current understanding of the vascularization of the precentral gyrus by distal ACA branches, in particular the PIFA.

Endovascular sacrifice of the proximal posterior inferior cerebellar artery for treatment of ruptured intracranial aneurysms

BackgroundRuptured aneurysms of the intracranial vertebral artery (VA) or posterior inferior cerebellar artery (PICA) are challenging to treat as they are often dissecting aneurysms necessitating direct sacrifice of the diseased...

Neurological Manifestation of COVID-19 and the Enhanced Role of Physiatrists.

Neurological Manifestation of COVID-19 and the Enhanced Role of Physiatrists.

Abstract TP467: Effects of the Tortuosity of the Cervical Internal Carotid Artery on Procedural Outcomes of Stent Placement

Introduction: Severe tortuosity of the cervical internal carotid artery distal to the stenosis may prevent successful placement of distal protection device and increase the risk of dissection and/or ischemic stroke. Objective: To assess and categorize the effects of tortuosity of the cervical internal carotid artery distal on procedural times, and peri-procedural complications in patients treated with carotid artery stent placement. Material and Methods: We analyzed the angiographic images and clinical data for a consecutive series of patients treated with stent placement over an 18-month period and graded the tortuosity as follows: Grade 0 is no vessel turns; Grade 1 (MILD) is 1 vessel turn, &gt;90 degrees; Grade 2 (MODERATE) is 1 vessel turn, ≤90 degrees; Grade 3 (SEVERE) is 2 vessel turns, any angle; Grade 4 (SEVERE) is two vessel segments which are parallel to due to interspersed loop; Grade 5 (SEVERE) is a complete vessel loop (360 degrees). Technical complications including unsuccessful attempts to cross the stenosis with interventional devices, unutilized distal embolic protection, iatrogenic dissection, and ischemic events were ascertained. Results: A total of 80 patients were identified who underwent stent placement; mean (SD) 67.4 (8), 60 (75%) were men. Forty-three patients (53.8%) had evidence of stroke on non-invasive imaging prior to stent placement. In sixty-five cases, stent placement was performed electively (81.3%), emergently in fifteen cases (18.8%). The tortuosity was graded as 1 (46.2%), 2 (11.3%), 3 (15%), 4 (6.3%), and 5 (2.5%). Of the 80 patients, eighteen (22.5%) had severe tortuosity of grade 3 or higher. Mean procedural time (SD) was significantly greater with severe vessel tortuosity compared to mild to moderate vessel tortuosity (51.6 (6.2) versus 42.3 (5.2) minutes, p=.042). Technical complication rates were not significantly different with severe vessel tortuosity compared with mild to moderate vessel tortuosity (7% vs 9% p=.53). One intra-procedural dissection occurred in a case of severe tortuosity (grade 5). Conclusions: Severely tortuous internal carotid arteries distal to the stenosis can be seen in one fifth of patients undergoing carotid stent placement and is associated with increased procedural times.

Antibodies against neural antigens in patients with acute stroke: joint results of three independent cohort studies.

Ischemic stroke (IS) and hemorrhagic stroke (HemS) typically lead to a breakdown of the blood-brain barrier with neural antigen presentation. This presentation could potentially generate destructive auto-immune responses. Pre-existing antineuronal and antiglial antibodies (AA), predominantly NMDA receptor antibodies, have been reported in patients with stroke. This article summarizes three independent prospective studies, the Lübeck cohort (LC), Barcelona cohort (BC), and Heidelberg cohort (HC), exploring the frequency and clinical relevance of AA in patients with acute stroke (AS). In all cohorts together, 344 consecutive patients admitted with AS (322 × IS, 22 × HemS) were screened for AA in serum at admission. Clinical outcome parameters as well as a second AA screening were available at 30days in the LC or at 90days in the BC. A control group was included in the BC (20 subjects free from neurological disease) and the HC (78 neurological and ophthalmological patients without evidence for stroke). The rate of positivity for AA was similar in control subjects and AS patients (13%, 95% CI [7%, 22%] vs. 13%, 95% CI [10%, 17%]; p = 0.46) with no significant difference between cohorts (LC 25/171, BC 12/75, HC 9/98). No patient had developed new AA after 30days, whereas 2 out of 60 patients had developed new AA after 90days. AA positive patients did not exhibit significant differences to AA negative patients in stroke subtype (LC, BC), initial stroke severity (BC, LC, HC), infarct volume (BC), and functional status at admission (BC, LC, HC) and follow-up (BC, LC). AS does not induce AA to a relevant degree. Pre-existing AA can be found in the serum of stroke patients, but they do not have a significant association with clinical features and outcomes.

PB2307 SICKLE CELL DISEASE PATIENTS HAVE NORMAL NEUTROPHIL OXIDATIVE BURST RESPONSE

Background:Bacterial infections are a frequent cause of acute morbidity and sometimes mortality in sickle cell disease (SCD). Splenic dysfunction alone does not explain the susceptibility to specific organisms e.g., Staphylococcus aureus and Klebsiella as shown in some studies; suggesting that the splenic dysfunction is not the only explanation and that neutrophil dysfunction may be present. Neutrophils destroy microbes by producing a burst of reactive oxygen species (ROS) (respiratory burst) in response to bacterial components, as well as to phorbol‐myristate‐acetate (PMA). Some studies have shown that the state of chronic hemolysis in SCD impairs the ability to develop neutrophils to mount a bactericidal oxidative burst, and hence increasing susceptibility to bacterial infections.Aims:to assess the neutrophil oxidative burst in SCD patients and explore the relation to markers of hemolysis.Methods:Twenty‐seven hydroxyurea naïve children and adolescents with SCD (mean age 11.1 ± 3.9 years) were enrolled from Pediatric Hematology Clinic at Ain Shams University Children's Hospital. They were compared to 26 age‐ and sex‐matched healthy controls. Patients were studied stressing on transfusion history, chelation therapy, serum ferritin, hematological profile, markers of hemolysis and serum haptoglobin. Neutrophil oxidative burst assay was performed using DHR based flow cytometry.Results:Eleven (40%) out of the 27 patients had HBSS while 16 (60%) patients were sickle thalassemias. Six patients (22.2%) were splenectomized. Severe vaso‐occlusive crisis and acute chest syndrome were found in 22.2% and 18.5% of patients, respectively. Four (14.8%) patients had evidence of stroke. Bone fractures and avascular necrosis were found in 5.5% and 11.1 % of patients, respectively. Most of the studied patients were on chelation therapy, either as monotherapy or combined chelation (37% each). White blood cell count and reticulocytic count were significantly higher in SCD patients as compared to healthy controls (P = 0.03 and &lt;0.01 respectively). All subjects, whether SCD or controls showed a normal neutrophil oxidative burst response to PMA‐stimulation. Unstimulated and PMA stimulated rhodamine fluorescence were comparable in SCD patients and controls, indicating normal basal production of reactive oxygen species, and normal oxidative burst in SCD patients (P = 0.09). We did not demonstrate any correlation between markers of hemolysis including reticulocytic count, indirect bilirubin, LDH, serum haptoglobin and DHR response in the SCD group.Summary/Conclusion:Neutrophils in SCD patients can mount a normal oxidative burst in response to PMA stimulation. This data excludes the role of impaired neutrophil oxidative burst as a risk for bacterial infections in SCD.