History Of TIA Research Articles

The Los Angeles motor scale (LAMS) is independently associated with CT perfusion collateral status markers

Background and aimThe Los Angeles Motor Scale (LAMS) is an objective tool that has been used to rapidly assess and predict the presence of large vessel occlusion (LVO) in the pre-hospital setting successfully in several studies. However, studies assessing the relationship between LAMS score and CT perfusion collateral status (CS) markers such as cerebral blood volume (CBV) index, and hypoperfusion intensity ratio (HIR) are sparse. Our study therefore aims to assess the association of admission LAMS score with established CTP CS markers CBV Index and HIR in AIS-LVO cases. Materials and MethodsIn this prospectively collected, retrospectively reviewed analysis, inclusion criteria were as follows: a) CT angiography (CTA) confirmed anterior circulation LVO from 9/1/2017 to 10/01/2023, and b) diagnostic CT perfusion (CTP). Logistic regression analysis was performed to assess the relationship between admission LAMS with CTP CS markers HIR and CBV Index. p ≤ 0.05 was considered significant. ResultsIn total, 285 consecutive patients (median age = 69 years; 56 % female) met our inclusion criteria. Multivariable logistic regression analysis adjusting for sex, age, ASPECTS, tPA, premorbid mRS, admission NIH stroke scale, prior history of TIA, stroke, atrial fibrillation, diabetes mellitus, hyperlipidemia, coronary artery disease and hypertension, admission LAMS was found to be independently associated with CBV Index (adjusted OR:0.82, p < 0.01), and HIR (adjusted OR:0.59, p < 0.05). ConclusionLAMS is independently associated with CTP CS markers, CBV index and HIR. This finding suggests that LAMS may also provide an indirect estimate of CS.

Edoxaban for stroke prevention in atrial fibrillation and factors associated with dosing: patient characteristics from the prospective observational ETNA-AF-China registry

Real-world data on effectiveness and safety of a single non-vitamin K antagonist oral anticoagulant in the Chinese population with atrial fibrillation (AF) are limited. This study reports characteristics of patients treated with edoxaban and factors associated with dosing patterns from routine care in China. ETNA-AF-China (NCT04747496) is a multicentre, prospective, observational study enrolling edoxaban-treated patients from four economic regions with a targeted 2-year follow-up. Of the 4930 patients with AF (mean age: 70.2 ± 9.5 years; male, 57.1%), the mean creatinine clearance (CrCl), CHA2DS2-VASc, and HAS-BLED scores were 71.2 mL/min, 2.9, and 1.6. Overall, 6.4% of patients were perceived as frail by investigators. Available label dose reduction criteria (N = 4232) revealed that 3278 (77.5%) patients received recommended doses and 954 (22.5%) non-recommended doses. Northeast (53.0%) and West (43.1%) regions had the highest prescriptions of 60 mg and 30 mg recommended doses, respectively. Non-recommended 30 mg doses were more frequently prescribed in patients with antiplatelet use and history of heart failure than recommended 60 mg. Multivariate analysis identified advanced age as the strongest associated factor with non-recommended doses. Frailty had the strongest association with 30 mg except for age, and history of TIA was the most relevant factor associated with 60 mg. In conclusion, patients in the ETNA-AF-China study were predominantly aged 65 years and older, had mild-to-moderate renal impairment and good label adherence. Advanced age was associated with non-recommended doses, with frailty most common for non-recommended 30 mg and a history of TIA for the non-recommended 60 mg dose.

Abstract TP150: Magnetic Resonance Imaging Predictors of Atrial Fibrillation in Cryptogenic Stroke Cases

Introduction: Ischemic stroke is a leading cause of death and disability in the US, with 20-40% of cases, classified as cryptogenic or with an unexplained cause. Detection of one cause, paroxysmal atrial fibrillation (AF), is critical to ensuring optimal treatment with direct oral anticoagulant (DOAC). Currently, the most reliable AF detection strategy is use of an insertable cardiac monitor (ICM). However, earlier detection of occult cardioembolic patterns using MRI may promote earlier decisions for DOAC use. The overall goal of this study is to determine if MRI lesion patterns are predictive of AF detection by ICM. Methodology: Cases of consecutive patients (1/1/2015 - 12/31/2017) with MRI-confirmed stroke performed 48h from time last known well and prior to endovascular treatment were retrospectively analyzed. The primary outcome, presence of occult atrial fibrillation, was detected by ICM placement within 90 days and follow-up within 180 days from stroke. Four imaging patterns were tested as predictors of AF: i) acute stroke lesion involving multiple vascular territories (MVT, i.e. right or left carotid and/or posterior circulation), ii) MVT plus wedge-shaped cortical infarct or chronic stroke on FLAIR, iii) MVT involving 3 territories, and iv) MVT in 3 territories plus chronic FLAIR lesion. Adjustment variables were based on univariate logistic regression predictors of AF at P ≤0.1000. Results: Of the 101 cases in this analysis, the median age was 63 years and 49.5% male. Stroke in multiple vascular territories MVT was present in 22/101 (22%) at baseline. The total AF 6-month detection rate was 36/101 (36%). The imaging pattern most predictive of AF was pattern ii, MVT plus chronic FLAIR with an unadjusted odds ratio (OR) of 3.47, 95% CI of 0.3442-2.1731, P=.0073. The adjusted OR (age ≥ 55, history of stroke, and history of TIA,) was 3.26, 95% CI: 1.0358-11.1860, P =.0480. Conclusion: The presence of acute lesions in MVT and a chronic FLAIR lesion may be a biomarker of occult cardioembolic source that could be used early after the onset of stroke to determine optimal DOAC use for secondary prevention and potential risk reduction of stroke recurrence from suspected but unproven cardioembolic source. Funding: Lone Star Stroke Research Consortium

The Compensation Index Is Better Associated with DSA ASITN Collateral Score Compared to the Cerebral Blood Volume Index and Hypoperfusion Intensity Ratio

Background: Pretreatment CT Perfusion (CTP) parameters serve as reliable surrogates of collateral status (CS). In this study, we aim to assess the relationship between the novel compensation index (CI, Tmax &gt; 4 s/Tmax &gt; 6 s) and already established CTP collateral markers, namely cerebral blood volume (CBV) index and Hypoperfusion Intensity Ratio (HIR), with the reference standard American Society of Interventional and Therapeutic Neuroradiology (ASITN) collateral score (CS) on DSA. Methods: In this retrospective study, inclusion criteria were the following: (a) CT angiography confirmed anterior circulation large vessel occlusion from 9 January 2017 to 10 January 2023; (b) diagnostic CT perfusion; and (c) underwent mechanical thrombectomy with documented DSA-CS. Student t-test, Mann–Whitney-U-test and Chi-square test were used to assess differences. Spearman’s rank correlation and logistic regression analysis were used to assess associations. p ≤ 0.05 was considered significant. Results: In total, 223 patients (mean age: 67.8 ± 15.8, 56% female) met our inclusion criteria. The CI (ρ = 0.37, p &lt; 0.001) and HIR (ρ = −0.29, p &lt; 0.001) significantly correlated with DSA-CS. Whereas the CBV Index (ρ = 0.1, p &gt; 0.05) did not correlate with DSA-CS. On multivariate logistic regression analysis taking into account age, sex, ASPECTS, tPA, premorbid mRS, NIH stroke scale, prior history of TIA, stroke, atrial fibrillation, diabetes mellitus, hyperlipidemia, heart disease and hypertension, only CI was not found to be independently associated with DSA-CS (adjusted OR = 1.387, 95% CI: 1.09–1.77, p &lt; 0.01). Conclusion: CI demonstrates a stronger correlation with DSA-CS compared to both the HIR and CBV Index where it may show promise as an additional quantitative pretreatment CS biomarker.

A Study of LDL Status of Stroke Patient Admitted in Tertiary Care Hospital

Background: Stroke is the leading cause of morbidity globally and the second most frequent cause of mortality after ischemic heart disease. Previous findings regarding the relationship between lipids and stroke were debatable. Objective: To observe LDL status of stroke patients in tertiary care hospital. Method: This cross-sectional observational study was conducted in the Medicine Unit of Sir Salimullah Medical College Mitford Hospital, Dhaka from August 2011 to January 2012. A total of 104 patients of any sexes who were clinically present with features of stroke and then confirmed on CT scan were included. Patients were randomly enrolled according to the selection criteria. Data were collected using a structured questionnaire. Patients demographic profile, co-morbidities, history of TIA, and lipid profile were collected and recorded. Data were presented as frequency with percentage in case of categorical data and mean and standard deviation in case of numerical data. The Chi- Square test and unpaired t test was used to analyze categorical and numerical data respectively. A value of p &lt;0.5 was considered statistically significant. Statistical software SPSS was used for data analysis. Result: The average age was 62.12±11.65 years. The majority of patients (61.5%) were men, while 38.5% were women. Out of 104 patients, 57.7% had high blood pressure, 33.7% had diabetes, 22.1% had IHD, and 26.0% had had a stroke or TIA in the past. 21.2% of the patients used smokeless tobacco, and about 41.3% smoked cigarettes. 73.1 percent of the patients had ischaemic strokes, and the remaining 26.9 percent had hemorrhagic strokes. It was found that dyslipidaemia was more frequently linked to ischaemic stroke than hemorrhagic stroke. Nearly 78.8% of stroke victims had high LDL levels, 44.2% had low HDL levels, 57.7% had high cholesterol, and 57.7% had high triglyceride levels. Patients who had ischaemic strokes were found to have higher levels of LDL than patients who had hemorrhagic strokes, but the difference was not statistically significant. Conclusion: Elevated LDL cholesterol was found higher in ischemic stroke patients than hemorrhagic stroke patients but there was no significant difference. Sir Salimullah Med Coll J 2023; 31: 53-59

Risk Factors and Outcome of Cerebrovascular Complications in Transplant Recipients (P14-5.013)

<h3>Objective:</h3> To determine the incidence of cerebrovascular complications, risk factors, and outcomes in transplant patients. <h3>Background:</h3> Post-Transplant patients experience a myriad of cerebrovascular (CV) complications including ischemic stroke (IS), TIA, SAH, ICH, and posterior reversible encephalopathy syndrome (PRES). These increase mortality and morbidity in an already susceptible population. <h3>Design/Methods:</h3> Retrospective observational study. Population: Patients ≥18 years of age who underwent solid organ transplantation since 2012 at a tertiary care center. Patients were divided into 2 groups, with CV complications and without. Outcomes of interest were the proportion of CV complications, length of stay (LOS), discharge disposition, functional outcomes (defined by a mRS), and survival time post-transplant. <h3>Results:</h3> A total of 94 patients met the inclusion criteria (31% with CV complications vs 69% patients without). The median age was 57.5 years (51.41 vs 45.75). IS was the most prevalent CV complication (n=13, 44%, most common etiology was cryptogenic 76.9% (n=11)) followed by ICH (n=6, 20%), and most of the complications occurred within 1 year post-transplant (n=17, 58.6%). A previous TIA or stroke predisposed to more CV complication post-transplant (OR 0.66 vs 4.89, p=0.05) but no difference was found for other risk factors when compared to recipients without complications. Patients with complications were more likely to have lung transplants (24.1% vs 1.5%, p&lt;0.05) and to be discharged to hospice (6.9% vs 0%, p&lt;0.05) or dead (27.6% vs 0%, p&lt;0.05) than those without complications, who were more likely to have kidney transplants (20.4% vs 79.6%, p&lt;0.05) and to be discharged home (17% vs 66%, p&lt;0.001). There was no difference for the other outcomes. <h3>Conclusions:</h3> Post-transplant patients, especially lung recipients, have a high incidence of CV complications and high mortality. A history of TIA or IS predisposes this population to subsequent CV events. LOS, demographic characteristics, use of antithrombotics, or survival time post-transplant was no different between groups. <b>Disclosure:</b> Dr. Cadena Tejada has nothing to disclose. Dr. Ozark has nothing to disclose. Dr. Gregoski has nothing to disclose. Dr. Grewal has nothing to disclose.

Abstract TP195: Risk Factors And Outcome Of Cerebrovascular Complications In Transplant Recipients

Introduction: Post Transplant patients experience a great variety of cerebrovascular (CV) complications including ischemic stroke (IS), TIA, SAH, ICH, and posterior reversible encephalopathy syndrome (PRES). These increase mortality &amp; morbidity in an already susceptible population but the incidence of these complications, risk factors, and outcomes in transplant recipients have not been examined in detail. Methods: Design: A retrospective observational study. Population: Patients &gt;18 years of age who underwent solid organ transplantation since 2012 at a tertiary care center. Patients were divided into 2 groups, with CV complications and without. Outcomes of interest were the proportion of CV complications, length of stay (LOS), discharge disposition, functional outcomes (defined by a mRS), and survival time post-transplant. Results: A total of 94 patients met the inclusion criteria (31% (n=29) with CV complications vs 69% (n=65) patients without). The median age was 57.5 years (51.41 vs 45.75 p&gt;0.05). IS was the most prevalent CV complication (n=13, 44%, most common etiology was cryptogenic 76.9% (n=11)) followed but ICH (n=6, 20%), and most of CV complications occurred within 1 year post-transplant (n=17, 58.6%). Patients with past history of TIA or stroke were more likely to have a CV complication post-transplant (OR 0.66 vs 4.89, p=0.05) but there was no significance for the other cardiovascular risk factors when compared to transplant recipients with no complications. Patients with complications were more likely to have lung transplants (p&lt;0.05) and to be discharged to hospice or dead than those without complications, who were more likely to have kidney transplants (p&lt;0.05) and to be discharged home (p&lt;0.001). There was no difference for the other outcomes of interest (p&gt;0.05). Conclusions: Post-transplant patients, especially lung transplants, have a high incidence of CV complications including stroke and higher case fatality. There was an association between a history of TIA or IS and subsequent CV events in our patient population. We did not demonstrate any difference in LOS, demographical characteristics, use of antithrombotic, or length of survival post-transplant in both the groups.

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Recanalization treatment for acute ischemic stroke: 3-month outcome before and after implementation of routine endovascular treatment.

Background and purposeEndovascular treatment for acute ischemic stroke has become a recommended treatment option for selected patients after several randomized controlled trials have shown the effectiveness of endovascular treatment. Due to the nature of randomized clinical trials, the generalizability to population based real life settings and the resulting benefits remain difficult to estimate.MethodsWe included 896 consecutive patients treated with intravenous thrombolysis (IVT) within 4.5 h of stroke onset between January 2016 and December 2018, who were treated with additional endovascular treatment according to the new evidence when indicated (new-IVT-cohort). This cohort was compared to 913 intravenous thrombolysis patients treated in the 4.5 h time-window between January 2011 and December 2013 before the era of endovascular treatment (old-IVT-cohort).ResultsIn the new-IVT-cohort there were 253 intravenous thrombolysis + endovascular treatment treated patients. The new-IVT-cohort was associated with a better outcome on the modified Rankin Scale at 3 months in univariable ordinal regression (OR 1.27; 95% CI 1.08–1.49). The association remained significant (OR 1.65; 95% CI 1.27–2.14) also after adjustment for following confounding factors: sex, NIHSS, diabetes, atrial fibrillation, hypertension, coronary artery disease, hypercholesterolemia, myocardial infarction, heart failure, history of ischemic stroke, history of TIA, and use of antithrombotic, statins, antihypertensive, anticoagulation treatment, or endovascular treatment (Fig. 1).ConclusionWe were able to verify the efficacy of endovascular treatment in a real life cohort of intravenous thrombolysis patients even when only 28% of the patients are eligible for endovascular treatment on top of intravenous thrombolysis treatment.

Association of Serum Neurofilament Light Chain Concentration and MRI Findings in Older Adults: The Cardiovascular Health Study.

Neurofilament light chain (NfL) in blood is a sensitive but nonspecific marker of brain injury. This study sought to evaluate associations between NfL concentration and MRI findings of vascular brain injury in older adults. A longitudinal cohort study included 2 cranial MRI scans performed about 5 years apart and assessed for white matter hyperintensities (WMH) and infarcts. About 1 year before their second MRI, 1,362 participants (median age 77 years, 61.4% women) without a history of TIA or stroke had measurement of 4 biomarkers: NfL, total tau, glial fibrillary acidic protein (GFAP), and ubiquitin carboxyl-terminal hydrolase L1. Most (n = 1,279) also had the first MRI scan, and some (n = 633) had quantitative measurements of hippocampal and WMH. In primary analyses, we assessed associations of NfL with a 10-point white matter grade (WMG) and prevalent infarcts on second MRI and with worsening WMG and incident infarct comparing the 2 scans. A p value <0.0125 (0.05/4) was considered significant for these analyses. We also assessed associations with hippocampal and WMH volume. In fully adjusted models, log2(NfL) concentration was associated with WMG (β = 0.27; p = 2.3 × 10-4) and worsening WMG (relative risk [RR] 1.24; p = 0.0022), but less strongly with prevalent brain infarcts (RR 1.18; p = 0.013) and not with incident brain infarcts (RR 1.18; p = 0.18). Associations were also present with WMH volume (β = 2,242.9, p = 0.0036). For the other 3 biomarkers, the associations for log2 (GFAP) concentration with WMG and worsening WMG were significant. Among older adults without a history of stroke, higher serum NfL concentration was associated with covert MRI findings of vascular brain injury, especially the burden of WMH and its worsening. Whether these results offer opportunities for the use of NfL as a noninvasive biomarker of WMH or to control vascular risk factors remains to be determined.

Ischemic Stroke Subtypes: Socio-demographic Factors, Risk Factors, and Outcomes in Southern Sri Lanka.

Stroke is a heterogeneous, catastrophic disease. A comprehensive clinical analysis of ischemic stroke (IS) risk factors and outcomes is crucial for optimum management in resource-poor settings. A prospective cross-sectional study of acute cerebrovascular disease (ACVD) involving 592 patients was conducted in a tertiary care center in Sri Lanka from November 2018 to May 2019. We aimed to describe the ACVD subtypes and the relationship of IS subtypes and subtype-categories (as defined by the Oxfordshire Community Stroke Project clinical classification) with risk factors, severity, and outcome. The majority (63.3%) had IS. Partial anterior circulation syndromes (PACS), total anterior circulation syndrome (TACS), posterior circulation syndromes (POCS), and lacunar syndromes (LACS) accounted for 102 (29.7%), 58 (16.9%), 88 (25.7%) and 95 (27.7%) of the cases, respectively. The most common PACS sub-category was higher-cerebral-dysfunction-with-homonymous-hemianopia (HCD+HH,39 cases;38.2%). Cerebellar-signs-without-long-tract-signs (CS-LTS) sub-category constituted the highest among POCS (47 cases; 53.4%). The leading sub-category within LACS was pure-motor (PM) strokes (43 cases; 45.3%).Patients aged ≥50 years (adjusted-OR [AOR]2.439; 95%CI,1.163-5.116;P=.018), IHD(AOR 2.520; 95%CI,1.347-4.713; P=.004) and BMI>23kg/m2(AOR 2.607; 95% CI,1.420-4.784; P=.002) were 2.5 times more likely to associate with TACS. Patients with a history of TIA (AOR 1.910; 95%CI,1.036-3.524; P=.038) and arrhythmias (AOR 5.933; 95%CI,3.294-10.684; P<.001) were 1.9 and 5.9 times more likely to be associated with POCS respectively. Those with hypertension were 2.3 times more likely to associate with LACS (AOR 2.233; 95%CI,1.270-3.926; P=.005).NIHSS(P<.001), mRS on admission (P=.001) and in 3 months (P<.001), deaths during hospital stay (P=.003) and within 28 days (P<.001) had a stronger relationship with individual stroke subtypes. The comparative risk of different IS subtypes depends on different risk factors. The findings of this study demonstrate that sub-categories within each stroke subtype may behave independently with regard to risk factors and outcomes, thus warranting the need for individual assessment.

Age-adjusted risk factors are independently associated with an increased risk of ischaemic stroke, transient ischaemic stroke and systemic embolism in the ETNA-AF-Europe registry

Abstract Background Oral anticoagulation is highly effective in preventing ischaemic stroke in patients with atrial fibrillation, but 1–2% of the patients suffer an ischaemic stroke upon anticoagulation. Outcomes are further influenced by various factors, and recent research has focussed on identifying risk factors that could be helpful in predicting stroke outcomes in anticoagulated patients. This could further assist clinicians in timely identification and management of high-risk patients. Purpose The present analysis aims to assess the age-adjusted risk predictors of ischaemic stroke and systemic embolic events (SEE) (including transient ischaemic attack [TIA]) during two-year follow-up of unselected European patients with AF in the ETNA-AF-Europe registry. Methods ETNA-AF-Europe is a prospective, multi-centre, post-authorisation, observational study conducted in 825 centres enrolling patients treated with edoxaban once daily in 10 European countries. Wald Chi square tested the association between risk predictors and stroke and SEE after adjusting for age, given that age is a well-known, strong predictor of stroke. Results A total of 13,417 patients with AF (edoxaban 60 mg: n=10,248; edoxaban 30 mg: n=3169) completed the two-year follow-up. The mean age was 73.6±9.5 years, with ∼84% of the patients aged over 65 years. The mean weight was 81.0±17.3 kg, estimated glomerular filtration rate was 74.4±30.5 ml/min/1.73m2 and males were 56.6%. The mean CHA2DS2-VASc and HAS-BLED scores were 3.2 and 2.5, respectively. Univariate analysis demonstrated that history of TIA at baseline was the strongest age-adjusted predictor of stroke and SEE (Wald Chi-square: 77.69; p&amp;lt;0.0001) (Figure 1), followed by CHA2DS2-VASc score (41.09; p&amp;lt;0.0001) (Figure 2), history of ischaemic stroke (29.47; p&amp;lt;0.0001), history of any stroke (all strokes combined including stroke of unknown/unspecified type) (29.18; p&amp;lt;0.0001), subjective frailty as assessed by physician (20.60; p&amp;lt;0.0001), and HAS-BLED score (17.22; p&amp;lt;0.0001). Conclusion History of TIA, CHA2DS2-VASc score, history of stroke, frailty and HAS-BLED score are independently associated with an increased age-adjusted risk of ischaemic stroke, TIA and SEE in anticoagulated patients with AF. These findings highlight the importance of optimising anticoagulation therapy in secondary prevention of TIA and in patients with high CHA2DS2-VASc scores, ensuring the correct use of NOACs - adherence and correct dosing - in this high-risk population. These findings also suggest that additional therapies could be needed to prevent stroke in this population. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Europe GmbH Figure 1. History of TIA as a predictorFigure 2. CHA2DS2-VASc score as a predictor

Prevalence and correlates of carotid artery stenosis in a cohort of Sri Lankan ischaemic stroke patients

BackgroundLarge artery atherosclerotic disease is an important cause of stroke, accounting for 15–46% of ischaemic strokes in population-based studies. Therefore, current guidelines from west recommend urgent carotid imaging in all ischaemic strokes or transient ischaemic attacks and referral for carotid endarterectomy. However, the clinical features and epidemiology of stroke in Asians are different from those in Caucasians and therefore the applicability of these recommendations to Asians is controversial. Data on the prevalence of carotid artery stenosis (CAS) among South Asian stroke patients is limited. Therefore, we sought to determine the prevalence and associated factors of significant CAS in a cohort of Sri Lankan patients with ischaemic stroke.MethodsWe prospectively studied all ischaemic stroke patients who underwent carotid doppler ultrasonography admitted to the stroke unit of a Sri Lankan tertiary care hospital over 5 years. We defined carotid stenosis as low (< 50%), moderate (50–69%) or severe (70–99%) or total-occlusion (100%) by North American Symptomatic Trial Collaborators (NASCET) criteria. We identified the factors associated with CAS ≥ 50% and ≥ 70% by stepwise multiple logistic regression analysis.ResultsA total of 550 ischaemic stroke patients (326 (59.3%) male, mean age was 58.9 ± 10.2 years) had carotid doppler ultrasonography. Of them, 528 (96.0%) had low-grade, 12 (2.2%) moderate and 7 (1.3%) severe stenosis and 3 (0.5%) had total occlusion. On multivariate logistic regression, age was associated with CAS ≥ 50% (OR 1.12, p = 0.001) and CAS ≥ 70% (OR 1.14, p = 0.016), but none of the other vascular risk factors studied (sex, hypertension, diabetes mellitus, smoking, past history of TIA, stroke or ischemic heart disease) showed significant associations.ConclusionsCarotid stenosis is a minor cause of ischemic stroke in Sri Lankans compared to western populations with only 4.0% having CAS ≥ 50 and 3.5% eligible for carotid endarterectomy. Our findings have implications for the management of acute strokes in Sri Lanka.

PILOT STUDY OF PERCUTANEOUS TEMPORARY DIAPHRAGM PACING WIRES IN CARDIAC SURGERY PATIENTS AT RISK OF PROLONGED MECHANICAL VENTILATION DURING THE COVID-19 PANDEMIC

BACKGROUNDProlonged mechanical ventilation (PMV) after cardiac surgery occurs in 12% of patients, and significantly increases morbidity and mortality. Diaphragm pacing (DP) decreases ventilation times by 64% in other patient groups. We investigated the feasibility and outcomes of DP in urgent cardiac surgeries to decrease ventilator burden during the COVID-19 pandemic.METHODS AND RESULTSThis pilot study is an open-label FDA (IDE# G170294) prospective trial of temporary DP electrode use in high risk cardiac surgery patients (ClinicalTrials.gov Identifier–NCT04309123). Prior to sternotomy closure, the pleural space is opened, two electrodes (Figure 1) are placed in each diaphragm muscle, and the wires are tunneled percutaneously. The electrodes record diaphragm burst electromyography (dEMG) continuously for the first 24 hours and then once daily (Figure 2). In PMV patients (MV>24 hours), DP is initiated to prevent diaphragm atrophy and ventilator induced diaphragm dysfunction. The primary outcome was incidence of serious device related adverse events. The secondary outcome was time on MV. From 4/2/20–6/25/20, 44 patients were consented, 32 were implanted, and 12 were not. PMV was required in 10 patients implanted and 4 not implanted. There were no serious adverse events related to DP electrode implantation, all stimulated patients had improved ventilation and diaphragm function, and all electrodes were removed successfully. Criteria that best predicted PMV were: IABP, history of TIA or CVA, COPD, LVEF < 20%, and prior open-heart surgery. Using these criteria, the median time on mechanical ventilation in the first 120 hours was 35.7% versus 80.0% for the stimulated and non-stimulated groups, respectively.CONCLUSIONTemporary DP electrode placement during cardiac surgery is feasible and safe. DP improved diaphragm function and ventilation, and increased the likelihood of extubation by 48 hours. These results provide a catalyst for a prospective randomized controlled trial to decrease the MV burden in an enhanced recovery after surgery (ERAS) protocol.

A-5 Examining the Interactive Effects of Traumatic Brain Injury and Apolipoprotein E on Cognitive Decline in Alzheimer’s Disease

Abstract Objective Little research has focused on possible effects of TBI on cognitive decline rate after Alzheimer’s disease (ad) diagnosis. We examined whether Apolipoprotein E (APOE) status and TBI history interact to predict cognitive decline. Method We used data from the National Alzheimer’s Coordinating Centers (N = 463; 42.3% APOE e4 carriers, 7.8% with TBI history, mean baseline age 79.3). Inclusion criteria included normal cognition at baseline with diagnosis of ad at a follow-up visit; baseline age 50 or older; and at least 3 years of follow-up data. Mixed models (random intercept, random slope) were used, with TBI history, APOE status, and their interaction as predictors of interest. Education, race, and history of TIA, stroke, or hypertension were included as covariates. Cognitive measures included mental status exam scores and immediate/delayed story memory. Results After accounting for covariates, TBI history had a positive effect on cognitive decline rate on the screener and immediate memory measures. APOE status did not affect rate of cognitive decline on the screener, but presence of e4 predicted faster decline on immediate and delayed memory. TBI history and APOE status interacted to predict delayed memory decline, such that history of TBI was associated with a reduced rate of decline for e4 non-carriers but there was no effect of TBI for e4 carriers. Conclusion When examining cognitive decline trajectory, TBI history predicted slower decline (a positive effect) while APOE had either a negative impact or no effect, depending on the measure. Future study should examine cognitive decline in the context of demographic and genetic factors.

A-010 Traumatic Brain Injury, APOE, and Age at Diagnosis of Alzheimer’s Disease

Abstract Objective Traumatic brain injury (TBI) is potentially a risk factor for Alzheimer’s disease (AD). This relationship may depend on the severity of TBI as well as other risk factors including APOE. We examined whether TBI status affects age of onset of AD, while improving on prior literature’s methodological issues. Method Data from the National Alzheimer’s Coordinating Centers were used. Inclusion criteria included: normal cognition at baseline; eventual diagnosis of AD; adults aged 50 and older; at least 3 years of follow-up data. Covariates included age at baseline and history of TIA, stroke, or hypertension. The resulting sample (N = 485) was 65.2% female; 89.1% White, 9.1% Black; and 4.5% Hispanic; 8% with TBI; and 42% with APOE4. Average age at baseline was 79.2 (SD = 7.6). ANCOVAs were used to determine whether TBI status (no TBI; TBI with brief LOC; TBI with extended LOC) was associated with earlier age of diagnosis for AD, controlling for age at baseline and health factors. APOE status was added to a second ANCOVA. Results Age at baseline (p &amp;lt; .001), but not health history (p = .777), was related to age of AD diagnosis. TBI status was not associated with age of AD diagnosis (p = .737). When APOE and the interaction between APOE and TBI status were added to the model, neither was significant (p’s = .150, .647). Conclusions When controlling for baseline cognition, age at baseline, and health factors, there was no relationship between TBI status and age of diagnosis of AD. However, use of more stringent inclusion criteria as compared to previous studies may have reduced power significantly.

Thrombolytic therapy in ischemic stroke patients with a preceding transient ischemic attack in telestroke and non‐telestroke settings

AbstractBackgroundThis study investigates the risk factors associated with exclusion or inclusion for thrombolytic therapy in TIA‐ischemic stroke patients in a telestroke compared with a non‐telestroke setting.MethodsThis study retrospectively analyzes regional stroke data collected between January 2010 and June 2016 from TIA‐ischemic stroke patients. We used the logistic regression model to predict clinical risk factors associated with exclusion or inclusion for thrombolytic therapy in the telestroke and non‐telestroke setting.ResultsThis study identified a total of 299 ischemic stroke patients with a history of TIAs. Of these, 98 patients received treatment in a telestroke setting, while 201 received treatment in a non‐telestroke setting. The telestroke excluded fewer patients (58%) and administered thrombolytic therapy to 42% of TIA‐ischemic stroke patients. The non‐telestroke setting excluded 89% of patients, while only 11% of TIA‐ischemic stroke patients received rtPA. In the telestroke setting, a history of previous TIA &gt; 24 hours (OR = 16.014, 95% CI, 4.112‐62.368, P &lt; .001) was associated with rtPA inclusion, while higher blood glucose levels (OR = 0.984, 95% CI, 0.969‐0.999, P = .042) were associated with an rtPA exclusion.ConclusionAfter adjusting for the effect of confounding variables, we found direct admission to be significant for exclusion in the non‐telestroke setting. Moreover, there was a significant association between hyperglycemia and exclusion from thrombolytic therapy in TIA‐ischemic stroke patients in the telestroke setting.

Cerebral revascularization by EC-IC bypass in ischemic conditions of different etiologies

Background: Even after the failure of EC-IC bypass trial, EC- IC bypass can help many patients in preventing future stroke. Here we present a case series of patients with cerebral ischemia from different etiological modes who underwent EC-IC bypass with positive end results. Methods: Patients in these cases series with TIA/stroke/recurrent stroke were evaluated clinically for the history of TIA or recurrent/hemodynamic TIA (in rest or during work) or progressive hemiparesis/aphasia/visual disturbances or sudden hemiplegia/hemiparesis/aphasia with subsequent significant (days to a week) recovery. MRI of the brain was done in ischemic protocol in all cases. To see the arterial pathology dynamic CTA was also done in all cases except one case. DSA was done in 03 cases. When clinical features, cerebral ischemia on MRI and arterial stenosis/occlusion on angiogram were concordant with each other, only then cerebral revascularization was done. After bypass, all patients were followed up regularly. All recorded data were reviewed retrospectively. Results: Total no. of cases were 08. The most common presentation was hemiparesis. Etiologies were infective thrombosis of ICA, orbital cellulitis, thrombosed giant ICA aneurysm, single &amp; multiple vessel occlusion and MCA stenosis. High flow EC-IC bypass was done in one case. STA- MCA bypass was done in rest of the cases. All patient were ambulant with static neuro-status without new stroke till last follow up. All bypasses were patent and functioning till last follow up (clinical, Doppler/Imaging). Conclusion: In carefully selected cases cerebral revascularization in ischemic conditions can result positive outcome.

The role of MRA in pediatric sickle cell disease with normal transcranial Doppler imaging velocities

PurposeThe purpose of this study was to determine the additional information provided by Magnetic Resonance Angiography (MRA) in pediatric sickle cell disease (SCD) patients with normal Transcranial Doppler imaging (TCDI) examinations. MethodsThis cohort study included all pediatric SCD patients over an 18-year period who had no history of stroke and had normal TCDI examinations and subsequently underwent MRA. Routine TCDI inclusive of time-averaged mean of maximum velocities (TAMMV) were assesses and compared with tortuosity on MRA and silent infarct on MRI. Results86 children (52.3% female; mean age 8.7 ± 3.5years) were included. There were 77 patients (89.5%) with Hb-SS disease and 9(10.4%) with HB-S beta-thalassemia. All patients had normal TAMMV (<170 cm/s) on TCDI. 76/86 (88.3%) patients also had one or more velocity readings <70 cm/s, albeit none in the middle cerebral arteries. Posterior cerebral arteries had the lowest velocities, <70 cm/s in 51.7% (right) and 60.9% (left). Silent MRI infarcts were seen in 27/86 (31.4%) patients. No new lesions were identified on follow-up MRI. Although mild vascular tortuosity was appreciated in 31/86 (36.0%) of the patients, there were no steno-occlusive lesions in the circle of Willis. ConclusionsTCDI and MRA are routinely performed for non-invasively evaluating intracranial vascular abnormalities in children with SCD. In SCD children with no history of TIA or stroke, MRA following a normal TCDI examination is unlikely to show vascular abnormality. However, almost a third of these patients show silent infarcts on MRI, unassociated with MRA changes.

MON-910 I’m Not Crazy! I Get a Headache When I Pee: A Case of Metastatic Bladder Paraganglioma

Tumors of chromaffin cells derived from the embryonic neural crest are classified as pheochromocytomas when located in the medulla of the adrenal glands and paragangliomas when located externally to it. Bladder paragangliomas constitute less than 1% of all catecholamine-secreting neuroendocrine tumors. Usually, these tumors are functional and symptomatic, but in other cases, they can be silent. We present an interesting case of a patient with post-micturition catecholaminergic crises that went undiagnosed for several years until found to have a bladder paraganglioma.A 60-year-old male with a past medical history of TIA, HTN, CAD, and ischemic cardiomyopathy presented with post-micturition headaches since age 14. Despite work up, no etiology was found. Eventually, the patient was referred to mental health for what was thought to be somatic symptoms. In 2010, he was diagnosed with hypertension and started keeping daily blood pressure (BP) logs, which showed BP fluctuation as high as 260s/110s with high-volume micturition, yet normotensive at other times. This led to imaging and cystoscopy which revealed a 6-cm bladder lesion. Surgical resection was completed, and pathology showed paraganglioma with positive margins and lymphovascular invasion. He was lost to follow up until 2017 when he presented with hypertensive crisis. CT and octreotide scan showed numerous osseous lytic lesions concerning for metastases. Laboratory testing confirmed excess catecholamines. He was referred to oncology, and after consideration of several treatment options, the patient was started on Xgeva and Sandostatin LAR. However, he passed away shortly thereafter.Bladder paragangliomas are very rare and account for 6% of extra-adrenal pheochromocytomas. They occur more frequently in women than in men and clinically present mainly during the third decade of life. The patient typically suffers from hypertensive crises that may be accompanied by headache, palpitations, hot flushes, and sweating. These crises are mainly provoked by micturition, overdistention of the bladder, defecation, sexual activity, ejaculation, or bladder instrumentation. If there is high suspicion, biochemical and functional imaging workup should be performed. Surgery is the mainstay of the treatment and requires total excision. If diagnosed preoperatively, a partial cystectomy is preferred over trans-urethral resection as the majority of these tumors extend in the deep layers of the detrusor muscle. Because they are likely to recur and to metastasize, annual follow up with a measurement of plasma and urinary catecholamine levels and cystoscopy are essential. A functional imaging study (Ga-DOTATE scan) should be done to locate recurrence if symptoms reappear or catecholamine resurgence occurs.