Pattern Of Infarction Research Articles

A CROSS-SECTIONAL STUDY OF RECOVERY PATTERN IN WATERSHED INFARCTS IN A TERTIARY CARE CENTRE.

Background: Acute ischaemic stroke is one of the leading causes of morbidity along with cancers and cardiovascular diseases. Millions suffer from acute ischaemic stroke every year worldwide of which 5% suffer from watershed infarcts(1). The aetiopathogenesis and recovery from decits in watershed infarcts are different from territorial infarcts. The identication of specic features of recovery pattern and pathogenesis of infarcts may throw more light on these diseases as modern-day treatment of stroke is mainly concentrated on the treatment of territorial infarcts like endovascular procedures. This study may help to ll that gap. Aim: To study the recovery pattern in acute watershed infarcts. Methodology: 153 patients with acute watershed infarcts were studied. Detailed examination, NIHSS Score, mRS scale and Barthel index were assessed at the presentation and after 90 days of follow-up. Patients with Cognitive impairments were assessed and followed up after 90 days. Statistical analyses were done using SPSS 25.0 software for Windows. Chi-square and independent t-tests were applied to analyze categorical and numerical data, respectively. Results: A total of 153 patients out of the 2233 acute strokes were studied. The mean NIHSS score, mRS scale, and Barthel Index in patients of watershed infarcts are 10.9,3.1,62.9, and after 90 days are 7.9,2.3, and 74.5 respectively. The comparison was statistically signicant. Most patients had signicant motor improvement and cognitive improvement. The most common etiology was Internal Carotid artery thrombosis which also had the best prognosis. Conclusion: The pathogenesis and recovery in Watershed Infarcts are different from that of territorial infarcts. Prognosis and Recovery depend upon the etiology. Both Motor and Cognition recovery in watershed infarcts is signicantly higher

Prevalence and Clinico-Radiologic Spectrum of Intracranial Atherosclerotic Disease-Related Stroke: An Observation from a Single Center in Saudi Arabia.

Intracranial atherosclerotic disease (ICAD) is an important etiologic subtype of acute ischemic stroke (AIS). However, little direct evidence is available regarding ICAD-related stroke in Saudi Arabia (SA). This study aimed to identify the prevalence and describe the clinico-radiological spectrum of ICAD-related AIS in a SA cohort. This was a hospital-based retrospective study enrolling patients with ICAD-related AIS between 2017 and 2020. The electronic charts were reviewed. The mechanisms of stroke were identified as artery-to-artery embolization (AAE), in situ thrombotic occlusion, hypoperfusion, or perforator branch occlusion. Pearson's χ2 test was performed to calculate the P values to establish the statistical significance of factors that could correlate with the mechanisms of stroke and functional outcome. ICAD was found in 133 of AIS comprising 26% of total. Data from all patients were reviewed. Left ICA (25%) was the most frequently affected vessel. Territorial pattern (63.9%) was the most common infarct pattern, and AAE (44.3%) was the most common underlying mechanism. Perforator branch occlusion was more prevalent in women than in men. Malignant and hemorrhagic transformation (P=0.00) were more prevalent in the AAE group. Left-sided vascular involvement was statistically associated with unfavorable outcomes than the right (P=0.019). The prevalence of ICAD in our cohort from Western Asia did not differ from that in Southern Asia. ICA involvement was observed more frequently than previously reported. Further research from SA is required to better understand ICAD-related strokes in this region.

The correlation of embolic sources with infarct pattern in patients with embolic stroke (P6-5.015)

<h3>Objective:</h3> To exclusively identify potential embolic sources (PES) applying transesophageal echocardiography (TEE) and correlate them with topographic diffusion-weighted imaging patterns (DWI) in patients with embolic stroke. <h3>Background:</h3> Embolic stroke of undetermined source (ESUS) has been reported to show a relatively high stroke recurrence rate. Thus, early identification of potential embolic source (PES) is critical for acute treatment and/or secondary prevention. If acute topographic diffusion-weighted imaging patterns (DWI) would correlate with specific PES, it may prove very useful. <h3>Design/Methods:</h3> A total of 992 consecutive patients with embolic stroke were studied. Apart from the known embolic group (n=560), we focused on the unknown embolic group (n=366) that was defined as no arrhythmia during the first day from admission and no PES after general examination. DWI were classified based on the arterial supply. Age and sex adjusted odds ratio (OR) of each DWI for the different PESs were calculated. Middle cerebral arteries (MCA) were divided into 4 segments, i.e., M1~M4. Moreover, M2 segments were subdivided into superior and inferior branches. <h3>Results:</h3> 366 patients consisted of 168 with paroxysmal atrial fibrillation (pAf), 82 with paradoxical embolism (PxE), 71 with aorto-embolism (AoE), leaving 39 patients undetermined. The DWIs of internal carotid artery (OR: 15.0, p=0.0027), M1 (4.2, p=0.0003), inferior M2 (3.6, p=0.04) and multiple cortical branches (MCB) (21.6, p&lt;0.0001) were significantly associated with pAf. Striatocapsular infarction (SCI) (15.1, p&lt;0.0001) was significantly associated with PxE and multiple small scattered infarcts (8.6, p&lt;0.0001) with AoE. <h3>Conclusions:</h3> The correlations of DWI with different PESs have their distinctive characteristics. The DWI of inferior M2 as well as large infarcts and multiple cortical infarcts were associated with pAf, that of SCI with PxE and MSS with AoE. The characteristic histopathology and hydrodynamic mechanism of thrombi may determine DWI. <b>Disclosure:</b> Yasumasa Yamamoto has nothing to disclose.

Early versus deferred coronary angiography following cardiac arrest. A systematic review and meta-analysis

AimThe role of early coronary angiography (CAG) in the evaluation of patients presenting with out of hospital cardiac arrest (OHCA) and no ST-elevation myocardial infarction (STE) pattern on electrocardiogram (ECG) has been subject to considerable debate. We sought to assess the impact of early versus deferred CAG on mortality and neurological outcomes in patients with OHCA and no STE. MethodsOVID MEDLINE, EMBASE, Web of Science and Cochrane Library Register were searched according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines from inception until July 18, 2022. Randomized clinical trials (RCTs) of patients with OHCA without STE that compared early CAG with deferred CAG were included. The primary endpoint was 30-day mortality. Secondary endpoints included mortality at discharge or 30-days, favourable neurology at 30-days, major bleeding, renal failure and recurrent cardiac arrest. ResultsOf the 7,998 citations, 5 RCTs randomizing 1524 patients were included. Meta-analysis showed no difference in 30-day mortality with early versus deferred CAG (OR 1.17, CI 0.91 – 1.49, I2 = 27%). There was no difference in favourable neurological outcome at 30 days (OR 0.88, CI 0.52 – 1.49, I2 = 63%), major bleeding (OR 0.94, CI 0.33 – 2.68, I2 = 39%), renal failure (OR 1.14, CI 0.77 – 1.69, I2 = 0%), and recurrent cardiac arrest (OR 1.39, CI 0.79 – 2.43, I2 = 0%). ConclusionsEarly CAG was not associated with improved survival and neurological outcomes among patients with OHCA without STE. This meta-analysis does not support routinely performing early CAG in this select patient cohort.

Abstract Number ‐ 239: Subcortical Infarcts in Patients with Nonstenotic Cervical Atherosclerotic Disease

Introduction Prior studies have elucidated a relationship between nonstenotic plaque in patients with cryptogenic embolic (cortical) infarcts, however it is unclear if nonstenotic carotid plaque is relevant in subcortical infarct patterns. Methods A nested cohort of consecutive patients with anterior, unilateral, subcortical infarcts without an identifiable embolic source were identified from a prospective stroke registry (September 2019 ‐ June 2021). Patients with extracranial stenosis &gt;50% were excluded. Patients with computed tomography angiography were included and comparisons made according to infarct pattern being lacunar (single lesion &lt; 1.5cm on computed tomography [CT] or &lt; 2.0cm on diffusion weighted imaging [DWI]) versus cryptogenic (≥ 1.5cm on CT or ≥ 2.0cm on DWI, or scattered subcortical lesions). Prevalence estimates for cervical internal carotid artery (ICA) plaque presence were estimated with 95% confidence intervals (CI), and differences in plaque thickness and features were compared between sides. Results Of the 1684 who were screened, 141 met inclusion criteria (n = 80 due to small vessel disease, n = 61 cryptogenic). The median age was 66y (interquartile range, IQR 58–73) and National Institutes of Health Stroke Scale score was 3 (IQR 1–5). There was a higher probability of finding excess plaque ipsilateral to the stroke (41.1%, 95%CI 33.3‐49.3%) than finding excess contralateral plaque (29.1%, 95%CI 22.2‐37.1%; p = 0.03), but this was driven by patients with cryptogenic infarcts (excess ipsilateral vs. contralateral plaque frequency of 49.2% vs. 14.8%, p&lt; 0.001) and not lacunar disease (35.0% vs. 40.0%, p = 0.51). Conclusions The probability of finding ipsilateral, nonstenotic carotid plaque in patients with subcortical cryptogenic strokes exceeds the probability of contralateral plaque and is driven by larger subcortical infarcts, classically defined as being cryptogenic. Approximately 1 in 3 unilateral anterior subcortical infarcts may be due to nonstenotic ICA plaque.

Abstract Number ‐ 10: Stroke Patients with Carotid Artery Web Have High RoPE Scores and Low Frequency of PFO

Introduction PFO‐associated stroke is more common in young patients (&lt;60 years) with less vascular risk factors, and with an infarct pattern consistent with embolic phenomena. These features are included in the Risk of Paradoxical Embolization (RoPE) score in which a high score (≥ 7) indicates a high likelihood of a symptomatic PFO. However, carotid artery webs (CaW) have been reported in patients with the same profile in which a PFO might be detected. In this study, we calculated RoPE score for patients with symptomatic CaW related strokes to identify how many of these patients would have been potentially misclassified as having a PFO‐associated stroke. Methods Patients presenting with ESUS and ipsilateral symptomatic CaW were included. Stroke work up was completed including cervicocranial vascular imaging that was reviewed by a neuroradiologist and an interventional neurologist. Shunt study was done with a TTE, TEE, and/or TCD, all with a bubble study. RoPE score of ≥ 7 was considered high. Results A total of 75 patients fulfilled the inclusion criteria of having an ipsilateral symptomatic CaW as the etiology of ESUS with no competing etiologies aside from PFO. The baseline characteristics are described in the table. The rates of vascular risk factors were generally low which is reflected by a high median RoPE score of 7 [IQR 5‐8], with 52% (n = 39) of patients having a score of ≥ 7. Ten patients (13%) had a PFO, of which 3 had high‐risk features. There was no significant difference in median RoPE score between patients with and without PFO (8 [6‐8] vs 6 [5‐8], p = 0.238), nor in the rate of patients with high RoPE score (78% vs 44%, p = 0.06). Recurrence happened in 16% (n = 12) of the patients and was always ipsilateral to the symptomatic CaW. No significant difference was detected in the rates of recurrence between high vs low RoPE scores (20.5% vs 11.1%, p = 0.351). Patients with a PFO had higher rates of recurrence compared to those without a PFO (40%, n = 4 vs 12.3%, n = 8, p = 0.048); however, none of the PFO patients with a recurrent stroke had a high‐risk PFO. A superimposed thrombus was seen on the CaW in 12.2% (n = 9) and was more commonly seen in patients who had recurrence (36%, n = 4 vs 8%, n = 5, p = 0.024). Conclusions Patients with ESUS from a presumably symptomatic CaW‐related stroke have high RoPE scores. The recurrence rates were high in this population and were always ipsilateral to the side of the CaW including in the PFO population. The PFO is likely incidental in this population despite having a high RoPE score. Neurologists should carefully evaluate the cervical vasculature before concluding that a PFO is stroke‐related and committing patients to PFO treatment.

Abstract WMP73: Border Zone Infarct Pattern Predicts Early Recurrence In Symptomatic Intracranial Atherosclerotic Disease: A Systematic Review And Meta-analysis

Introduction: Stroke secondary to intracranial atherosclerosis (ICAD) results in three distinct infarct patterns: (a) border zone infarcts (BZI) due to impaired distal perfusion (b) territorial infarcts due to distal plaque/thrombus embolization, and (c) perforator infarcts due to plaque progression. Previous studies indicate higher stroke recurrence in ICAD patients with BZI. Methods: This registered systematic review (CRD42021265230) comprised Medline and Web of Science search from inception to March 2022 for keywords (Intracranial Atherosclerosis OR Intracranial Stenosis) AND (Border zone OR Infarct Pattern) to identify papers and conference abstracts reporting initial infarct patterns and recurrence rates in patients with symptomatic ICAD. Sensitivity analyses were performed for studies including any BZI vs isolated BZI and those excluding posterior circulation strokes. The study outcome included neurological deterioration and/or stroke recurrence. For all outcome events, corresponding risk ratios (RR) and 95% confidence intervals (CI) were calculated. Risk of bias assessments will be presented. Results: Literature search yielded 4478 studies,11 met inclusion criteria (n=1315 patients, 354 with BZI, weighted proportions summarized in figure). The meta-analysis of these studies with moderate heterogeneity (I 2 =38.7%) demonstrated that RR of outcomes in BZI group compared to non-BZI group was 2.10 (95% CI 1.52-2.90). Limiting analysis to studies including any BZI, RR (and 95% CI) was 2.32 (1.58-3.40), and 3.25 (2.09-5.07) for studies only including anterior circulation strokes with low heterogeneity for both (I 2 =0%). A non-significantly high outcome rate was seen with isolated BZI (RR 2.29, 95% CI 0.94-5.62) but with moderate heterogeneity across studies (I 2 =70.25%). Conclusion: We demonstrate the presence of BZI secondary to symptomatic ICAD can be imaging biomarker to predict neurological deterioration and/or stroke recurrence.

Abstract WP97: Routine MRI Reveals Prior Stroke In The Same Vascular Territory In Half Of Patients Presenting With Acute Ischemic Stroke Due To Intracranial Atherosclerotic Disease

Introduction: In 2012, after SAMMPRIS demonstrated worse 30-day outcomes with Wingspan intracranial stent placement for intracranial atherosclerotic disease (ICAD), the FDA narrowed the “on-label” indication to a very specific subset of patients with symptomatic ICAD. The updated criteria require a prior stroke in the territory of the symptomatic vessel based on clinical history. Limitations in the accuracy of diagnosis of clinical stroke may be overcome with the use of MRI to identify any prior stroke - whether clinical or subclinical - which could expand the number of patients who are eligible for stenting. Methods: This was a retrospective analysis of consecutive cases of acute ischemic stroke attributable to ICAD with 50-99% stenosis in the symptomatic vessel from July 2019 - June 2022. MRI FLAIR sequences were reviewed for imaging evidence of prior infarction in the vascular territory of the symptomatic vessel. Subgroup analysis was performed based on stroke location, infarct pattern, degree of stenosis, and premorbid medication use. Results: 73 patients met inclusion criteria. Mean age was 72, and 41% were women. 37 patients (51%) exhibited MRI evidence of prior stroke in the same vascular territory. Of these, only 18/37 (49%) reported a prior clinical stroke. The frequency of prior stroke on MRI was similar with anterior (51%) and posterior (50%) circulation ICAD. Frequency of prior stroke based on infarct pattern was 64% for border zone infarction, 42% for thromboembolism, and 55% for branch atheromatous disease. Of the 31 patients who had degree of stenosis quantified on DSA, the frequency of prior infarction was 63% in patients with 70-99% stenosis versus 48% in those with &lt;70% stenosis. Only 1 patient (1.4%) met FDA on-label criteria for intracranial stenting. The most common reason for ineligibility was absent history of clinical stroke in the territory of the symptomatic vessel (75%). Conclusions: In patients presenting with acute stroke due to symptomatic ICAD, half exhibit MRI evidence of a prior stroke in the symptomatic arterial territory, and half of these prior strokes are not reported from clinical history. Routine MRI can be a valuable tool to identify prior stroke in the symptomatic territory, which may in turn expand therapeutic options for ICAD.

Abstract TMP71: Hypoperfusion And Thromboembolism Are Codominant Stroke Mechanisms In Adult Moyamoya Disease

Background: Treatment of moyamoya disease (MMD) has predominantly focused on flow augmentation since the mechanism of ischemic stroke has largely been attributed to hemodynamic failure. Recent studies have challenged this notion suggesting that thromboembolism may play a dominant role. The aim of our study was to investigate the mechanisms of ischemic stroke in MMD by assessing the relationship between infarction patterns and Quantitative Magnetic Resonance Angiography (QMRA) flow state. Methods and Results: This is a retrospective study of adult patients with suspected MMD that presented with MRI confirmed acute ischemic stroke predating or following QMRA by a maximum of six months, between 2009 and 2021. Of the 177 consecutive patients with MMD that underwent QMRA, 35 patients met inclusion, consisting of 41 hemispheres. Flow-status was dichotomized into low-flow and normal-flow based on published criteria. Mixed pattern was the most frequent finding (70.7%), followed by embolic (17.1%), perforator (7.3%), and internal borderzone (IBZ) (4.9%). Infarction patterns were then dichotomized into IBZ+ (internal borderzone alone or mixed) and IBZ- (no internal borderzone constituent) based on the constituents of the patterns. Low-flow states were insignificantly more frequent with IBZ+ compared to IBZ- (48.4% vs. 20.0%, p = 0.14). Ipsilateral PCA fractional flow was significantly higher with IBZ+ compared to IBZ- (345.0% vs. 214.7%, p = 0.04). Conclusions: Mixed infarction pattern was the most common pattern of infarction in patients with MMD, implying that at least 2 interrelated stroke mechanisms of hypoperfusion and thromboembolism likely coincide. An association between ICA flow status and the pattern of infarction was not found. Prospective studies evaluating the utility of antithrombotic agents in MMD are needed.

Disentangling poststroke cognitive deficits and their neuroanatomical correlates through combined multivariable and multioutcome lesion-symptom mapping.

Studies in patients with brain lesions play a fundamental role in unraveling the brain's functional anatomy. Lesion-symptom mapping (LSM) techniques can relate lesion location to cognitive performance. However, a limitation of current LSM approaches is that they can only evaluate one cognitive outcome at a time, without considering interdependencies between different cognitive tests. To overcome this challenge, we implemented canonical correlation analysis (CCA) as combined multivariable and multioutcome LSM approach. We performed a proof-of-concept study on 1075 patients with acute ischemic stroke to explore whether addition of CCA to a multivariable single-outcome LSM approach (support vector regression) could identify infarct locations associated with deficits in three well-defined verbal memory functions (encoding, consolidation, retrieval) based on four verbal memory subscores derived from the Seoul Verbal Learning Test (immediate recall, delayed recall, recognition, learning ability). We evaluated whether CCA could extract cognitive score patterns that matched prior knowledge of these verbal memory functions, and if these patterns could be linked to more specific infarct locations than through single-outcome LSM alone. Two of the canonical modes identified with CCA showed distinct cognitive patterns that matched prior knowledge on encoding and consolidation. In addition, CCA revealed that each canonical mode was linked to a distinct infarct pattern, while with multivariable single-outcome LSM individual verbal memory subscores were associated with largely overlapping patterns. In conclusion, our findings demonstrate that CCA can complement single-outcome LSM techniques to help disentangle cognitive functions and their neuroanatomical correlates.

Post-traumatic Early Cerebral Infarct: MRI-based Analysis of Incidence and Radiological Distribution

Introduction: Traumatic Brain Injury (TBI) is an alteration in brain function brought on by external trauma. Computed Tomography (CT) scanning is the mainstay diagnostic modality for evaluating the primary injury, as well as secondary events such as oedema, mass effect, herniation, infarction, etc., which are often catastrophic and responsible for morbidity and mortality. Early cerebral infarction, unless large and in a defined vascular territory, is quite likely to be missed on CT scans and can even be confused with cerebral oedema. In the diagnosis of early infarctions, especially the lacunar types, the detection rate of lesions with Magnetic Resonance Imaging (MRI) is significantly higher than that of CT. Aim: To observe the incidence, distribution, and pattern of Post-traumatic Cerebral Infarction (PTCI) and its association with neurological deterioration. Materials and Methods: In this cross-sectional study, 55 patients with head injuries admitted to the Department of Neurosurgery were evaluated between 72 to 96 hours posttrauma using Magnetic Resonance Imaging (MRI) of the brain (1.5 Tesla Siemens). Observations were made regarding the presence and pattern of any infarction, as well as its impact on the patients. Results: Post-traumatic early cerebral infarction was detected in 19 out of 55 (34.5%) patients. Infarct distribution was observed in nearly all defined vascular territories, with the most common occurrence in the Middle Cerebral Artery (MCA) territory. Neurological deficit was observed in four out of 19 infarcted cases during the hospitalisation period. Conclusion: Post-traumatic early cerebral infarction is common in head injuries and can lead to neurological deterioration. MRI is sensitive in detecting infarcts, especially the lacunar ones.

Incidence and Distribution of Various Arterial Territories Involved in Postoperative Neurological Complications in Patients Undergoing Cardiovascular Surgery: A Single Centre Retrospective Analysis

Background: Neurological complications (NCs) (stroke) remain a devastating complication after cardiovascular surgical procedures despite advances in perioperative monitoring and management. The incidence of NC related to cardiovascular surgeries (CS) is comparatively very high and associated with high morbidity and mortality. The aim of this study is to evaluate the overall incidence of neurological complications in adult as well as pediatric patients and various pattern of neurological injury on noncontrast computed tomography head (NCCT) associated with various types of CS. Materials and Methods: We retrospectively analyzed all the NCCT heads of the postoperative cardiovascular surgery patients done in the immediate and early postoperative period (&lt;7 days) who developed postoperative neurological deficits between April 2016 and February 2020. The medical records of all these cardiac surgery patients were analyzed for various variants such as the total number of patients who underwent CS, various types of cardiac surgery done during the study period, demographic information, associated comorbidities, various types of NC, postoperative data and various spectrum of computed tomography (CT) findings in the brain. Results: A total of 12,896 adult and pediatric cardiac surgeries were performed at our institute. Out of these, 1115 patients (8.6%) underwent CT brain for suspected neurological injury. A total of 215 patients (1.6%) had a positive finding on their NCCT head. Out of 215 patients, 148 (68.9%) were adult patients, whereas 67 (31.1%) were pediatric patients. A total of 156 (72.5%) patients had ischemic infarction (stroke), whereas hemorrhagic lesions were present in 59 patients (27.4%). The various types of positive CT scan findings were-156 ischemic infarcts (72.5%), 20 intraparenchymal hemorrhages (9.3%), 16 subdural hemorrhage (7.4%), 15 subarachnoid hemorrhage (6.9%), 01 cerebrovascular thrombosis (0.4%), and 07 intraventricular hemorrhage (3.2%). In an adult patient, pattern of ischemic infarct comprised middle cerebral artery (MCA) territory in 42 patients (41.5%), posterior territory in 34 patients (33.6%), anterior cerebral territory in seven patients (7.0%), multi-territory infracts in 11 patients (11.0%) and global ischemia in six patients (6.0%). Intraparenchymal hemorrhage was present in 17 patients (11.4%). In a pediatric subset of patient, the pattern of ischemic infarct included global hypoxic injury (GHI) in 30 patients (54.5%), posterior cerebral artery territory in nine patients (16.3%), MCA territory in eight patients (14.5%), multi-territory involvement in five patients (9.0%), and anterior cerebral artery territory in three patients (5.4%). In the hemorrhage group, five patients (7.4%) developed subarachnoid hemorrhage (SAH). Conclusion: In an adult patient, subset MCA territory infarcts were common in the infract group, whereas intra parenchymal haemorrhage (IPH) in the hemorrhage group. In the pediatric patient subset, GHI was common in infract group and SAH in hemorrhage group. Moreover, NCCT of the head is very useful in diagnosing early postoperative neurological complications in cardiovascular surgeries and managing the complications accordingly.

Borderzone infarction and recurrent stroke in intracranial atherosclerosis

BackgroundIntracranial stenosis (ICAS) is a common cause of stroke worldwide and patients with symptomatic ICAS exhibit a high rate of recurrence, particularly in the early period after the initial event. In this study, we aimed to study the association between borderzone infarct and recurrent ischemic stroke in patients hospitalized with symptomatic ICAS. MethodsThis is a retrospective single center study that included patients hospitalized with acute ischemic stroke in the setting of intracranial stenosis (50% or more and an acute ischemic stroke in the territory supplied by the stenosed artery) over a 32-month period. We excluded patients who did not receive a brain MRI or did not have an infarct on brain imaging. The primary predictor is infarct pattern (any borderzone vs. no borderzone infarct) and the primary outcome was recurrent cerebrovascular events (RCVE) within 90 days. We used unadjusted, and age and sex adjusted logistic regression models to determine associations between infarct pattern and RCVE at 90-days. ResultsAmong 99 patients who met the inclusion criteria (4 tandem), the mean age was 70.1 ± 11.2 years and 41.4% were women; 43 had borderzone infarcts and 19 had RCVE. In adjusted binary logistic regression analysis, borderzone infarct was associated with increased risk of RCVE (adjusted OR 4.00 95% CI 1.33-11.99, p=0.013). The association between borderzone infarction and RCVE was not different among anterior circulation ICAD (adjusted HR 2.85 95% CI 0.64-12.76, p=0.172) vs. posterior circulation ICAD (adjusted HR 6.69 95% CI 1.06-42.11, p=0.043), p-value for interaction = 0.592. ConclusionIn real world post-SAMMPRIS medically treated patients with ICAD, the borderzone infarct pattern was associated with 90-day RCVE. Borderzone infarcts are likely a surrogate marker of impaired distal blood flow, highlighting the importance of targeting stroke mechanisms and developing alternative treatment strategies for high-risk cohorts.

Cryptogenic stroke. Part 3: atrial cardiopathy and silent atrial fibrillation

Atrial cardiopathy (AC) and silent atrial fibrillation (AF) are potential causes of embolic cryptogenic stroke (embolic stroke of undetermined source, ESUS) timely diagnosis of which can significantly change the direction of secondary prevention and reduce the risk of repeated brain catastrophe. The article discusses clinical and radiological markers of cardioembolism, the concept of atrial cardiopathy, its electrocardiographic, echocardiographic and serum markers, as well as the possibility of drug prophylaxis of recurrent stroke. The most applicable AC features in daily operation are the ECG data (p-wave terminal force in lead V1 &gt; 5000 μV x ms, supraventricular extrasystoles and advanced interatrial block), 24-hour ECG monitoring (≥ 480 supraventricular extrasystoles per 24-hour, paroxysms of supraventricular tachycardia ≥ 20 complexes), transthoracic (diameter of left atrium &gt; 40 mm, index of diameter of left atrium ≥ 3 cm/m2, index of volume of left atrium &gt; 34 ml/m2) and transesophageal echocardiography (spontaneous echo contrast phenomenon, blood flow rate in LA appendage &lt;20 cm/s) and NT-proBNP concentration &gt; 250 pg/ml. An individual, interdisciplinary decision to prescribe an anticoagulant when combined: (1) the presence of structural and functional AC markers, (2) cardioembolic pattern of a cerebral infarction or intracranial artery occlusion by visualization data and (3) high thromboembolic risk and probability of detection of AF on assessment scales (CHA2DS2-VASc, AF-ESUS and C2HEST). The greatest benefit of prescribing anticoagulant therapy can be obtained by patients with recurrent ESUS in whom sufficient secondary prevention and expressed AC, typical cardioembolism imaging pattern and high risk of thromboembolic events have already been achieved.

Abstract 15675: Mid-Ventricular Hypertrophic Cardiomyopathy Presenting With Minoca

Background: Mid-ventricular hypertrophic obstructive cardiomyopathy (HOCM) is an uncommon form of cardiomyopathy that is linked to an apical aneurysm, increasing the risk of sudden death. Cases: We described four patients who presented with chest pain or SOB. Troponin elevation, acute myocardial infarction on cardiac MRI and absence of obstructive coronary disease confirmed the diagnosis of MINOCA. Echo revealed a pressure gradient between the apical and basal chambers of the left ventricle. Cardiac MRI showed mid-ventricular HOCM and mid-cavity obliteration with akinetic apical chamber LGE revealed areas of sub-endocardial or transmural myocardial infarction at the level of obstruction and at the apical segments distal to the obstruction. The presence of myocardial edema on tissue mapping in the same area suggested acute myocardial injury (Figure). Discussion: The pathogenesis of development of apical myocardial scarring and aneurysm formation in mid-ventricular HOCM remains unknown. Other variant of hypertrophic cardiomyopathy shows mid-myocardial foci of scar inside the hypertrophied segments, indicating fibrosis. Whereas in our patients, the LGE revealed a sub-endocardial or transmural infarct (myocardial infarction pattern) - an uncommon pattern in other hypertrophic cardiomyopathy variants. This pattern and elevation of troponin during the acute phase of illness supports the hypothesis that apical aneurysm is due to apical myocardial ischemia in mid-ventricular HOCM. Tissue characterization and pattern of scar by cardiac MRI in these patients could be useful in understanding the pathophysiology of this type of HOCM.

Wall characteristics of atherosclerotic middle cerebral arteries in patients with single or multiple infarcts: A high-resolution MRI Study.

Understanding the stroke mechanism of middle cerebral artery (MCA) atherosclerosis may inform secondary prevention. The aim of this study was to explore the relationship between vascular wall characteristics and infarction patterns using high-resolution magnetic resonance imaging (HRMRI) and diffusion-weighted imaging (DWI). From November 2018 to March 2021, patients with acute ischemic stroke due to MCA atherosclerotic disease were retrospectively analyzed. The wall characteristics of atherosclerotic MCA, including conventional characteristics and histogram-defined characteristics, were evaluated using HRMRI. Patients were divided into single-infarction and multiple-infarction groups based on DWI, and wall characteristics were compared between the two groups. Of 92 patients with MCA plaques, 59 patients (64.1%) had multiple infarcts, and 33 (35.9%) had single infarcts. The histogram-defined characteristics showed no differences between the single-infarction and multiple-infarction groups (P>0.05). Plaque burden, degree of stenosis, and prevalence of intraplaque hemorrhage (IPH) were significantly greater in the multiple-infarction group than in the single-infarction group (plaque burden: P = 0.001; degree of stenosis: P = 0.010; IPH: P = 0.019). Multivariate analysis showed that plaque burden (odds ratio: 1.136; 95% confidence interval: 1.054-1.224, P = 0.001) and IPH (odds ratio: 5.248; 95% confidence interval: 1.573-17.512, P = 0.007) were independent predictors for multiple infarction. IPH and plaque burden are independently associated with multiple infarcts. HRMRI may provide new insight into the mechanisms underlying the different MCA infarction patterns.

A clinical study of artery of Percheron infarction

Artery of Percheron (AOP) infarction, a rare cause of acute altered mental status (AMS), is characterized by bilateral paramedian thalamic infarction. The aim of this study was to review the clinical manifestation, radiological patterns, treatment, and prognosis of patients with AOP infarction. This retrospective case series included patients with AOP infarction from 2009 to 2020 from a medical center in Taiwan. We defined AOP infarction as acute bilateral paramedian thalamic infarction from magnetic resonance imaging, and patients were further categorized by their additional AOP territorial involvements. We determined outcomes with the modified Rankin Scale at discharge. Among the 10 included patients, AMS was the most common presentation (90%). We identified two patients with bilateral vertebral artery (VA), five with unilateral posterior cerebral artery (PCA), and one with bilateral PCA occlusion. Atherosclerosis was the most common presumed etiology (60%). Two and eight patients had favorable and unfavorable prognoses, respectively. PCA occlusion, rather than VA and BA occlusion, was common in angiography. Residual symptoms often resulted in significant disability at discharge. Basilar tip syndrome may share indistinguishable thalamic infarct patterns with AOP infarction but could be differentiated by angiography and other infarcted territories.

European Physician Survey Characterizing the Clinical Pathway and Treatment Patterns of Patients Post-Myocardial Infarction.

The 2019 European Society of Cardiology and European Atherosclerosis Society (2019 ESC/EAS) guidelines stress the importance of managing low-density lipoprotein cholesterol (LDL-C) after myocardial infarction (MI) to reduce the risk of cardiovascular events. Information on guideline implementation is limited. The aim of this survey was to describe current clinical practice regarding LDL-C management in the first year post-MI across Europe, improving understanding of the role of ESC/EAS guidelines on clinical practice. A qualitative web-based cross-sectional physician survey about the patient pathway and LDL-C management post-MI was conducted in 360 physicians from France, Italy, Germany, The Netherlands, Spain, and the UK (n = 60/country) between December 2019 and June 2020. Secondary and primary care physicians (SCPs/PCPs) described their experiences treating patients post-MI over the preceding 2months. Physicians reported that on average 90.7% of patients not prescribed lipid-lowering therapy (LLT) before an MI initiated LLT as inpatients; for patients already taking LLT, treatment was intensified for 64.7% of inpatients post-MI. SCPs reported prescribing higher-intensity statins and/or ezetimibe for between 72.3% (Italy) and 88.6% (UK) of patients post-MI. More than 80.0% of SCPs and 51.2% of PCPs stated that they would initiate a change in LLT immediately if patients did not achieve their LDL-C treatment goal by 12weeks post-MI; 82.0% of SCPs and 55.1% of PCPs reported referring to 2019 ESC/EAS guidelines for management of patients post-MI. Barriers to initiating PCSK9 inhibitors (PCSK9is) included prior prescription of a maximally tolerated dose of statin (49.4%) and/or ezetimibe (38.9%), requirement to reach threshold LDL-C levels (44.9%), and pre-authorization requirements (30.4%). Differences in clinical practice post-MI were reported across the countries surveyed, including divergence between 2019 ESC/EAS and local guidelines. Increased use of innovative medicines to achieve LDL-C goals should reduce risk of subsequent cardiovascular events in very high-risk patients post-MI.

The mucormycosis and stroke: The learning curve during the second COVID-19 pandemic

BackgroundThe Angio-invasive Rhino-orbito-cerebral mucormycosis (ROCM) producing strokes is a less explored entity. Our hospital, a stroke-ready one, had an opportunity to manage mucormycosis when it was identified as the nodal center for mucormycosis management. We are sharing our experiences and mistakes in managing the cerebrovascular manifestations of ROCM. MethodsWe conducted a prospective observational study during the second wave of the COVID-19 pandemic from 1st May 2021 to 30th September 2021, where consecutive patients aged more than 18 years with microbiologically confirmed cases of ROCM were included. Clinical details (timing of stroke onset after ROCM symptoms, GCS, NIHSS), imaging findings (ASPECTS, the territory of stroke, the pattern of infarct, hemorrhagic transformation, cavernous sinus thrombosis), angiogram findings, management details (IV thrombolysis), and outcomes (mRS at discharge and duration of hospital stay) were documented. We also compared the demographics, clinical features (NIHSS), radiological findings, treatment details, duration of hospital stay, and functional outcome at the discharge of the ROCM stroke patients with stroke patients without ROCM. ResultsStroke developed in 42% of patients with ROCM, predominantly anterior circulation border zone ischemic infarcts. Strokes occurred after a median of five days from the onset of ROCM symptoms. The most common vessel involved was the ophthalmic artery, followed by the cavernous ICA. We could not thrombolyse ROCM stroke patients. ROCM patients who developed stroke compared with patients without stroke had a more infiltrative fungal infection and higher inflammatory markers. Mucormycosis associated stroke patients had higher in-hospital mortality and poor functional outcomes.T ConclusionDue to delayed recognition of stroke symptoms, none received reperfusion strategies, leading to poor functional outcomes. For early stroke detection, ROCM cases need frequent monitoring and education of patients and their relatives about the ALS acronym (loss of ambulation, limb weakness, and loss of speech).

Differential electrocardiographic changes related to the culprit coronary artery in patients with acute myocardial infarction and left bundle branch block

Abstract Background The electrocardiographic (ECG) recognition of acute myocardial infarction (AMI) in patients with concurrent left bundle branch block (LBBB) is hampered by background changes in QRS complex duration and ST segment, potential directly caused by LBBB. Currently available ECG algorithms were constructed to suspect the presence of AMI but they not take into a count the culprit coronary artery and this fact could explain their low sensitivity. Objectives To analyze the influence of the culprit coronary artery on the ECG changes and on the diagnostic yielding of ECG algorithms in patients with acute myocardial infarction and LBBB. Methods We analyzed the index ECG of 240 patients with acute chest pain and LBBB referred to emergent coronary angiography. Patients were classified in 3 groups according their coronary anatomy: a) acute coronary occlusion (n=48); b) critical non occlusive lesion (n=45); and c) absence of coronary lesions (n=76). In all ECGs we measured the ST-segment shifts and QRS duration and compared the pattern of changes in relation to the culprit coronary artery. Results Location of the culprit coronary artery induced differential ECG patterns: a) mean ST segment elevation ≥3mm in leads V2-V3 in patients with LAD occlusion (n=27); b) absence of ST segment depression in leads V5-V6 in LCX occlusion (n=11); and c) mean ST segment elevation ≥1.5 mm in leads III-aVF and attenuation of the ST elevation in leads V1-V2 (mean &amp;lt;1mm) in cases of RCA occlusion (n=10). Patients with critical non occlusive lesions (n=45) did not show particular ECG changes. QRS complex duration was longer in patients with LCX occlusion. Sensitivity of the Sgarbossa score was around 50%, sensitivity of the Smith score was &amp;gt;70% in all coronary groups and sensitivity of Barcelona score was really good for LCX and RCA occlusion. The combination of the three algorithms increased the sensitivity in all groups (&amp;gt;74%) but more markedly in patients with LCX occlusion (90.9%) and RCA occlusion (90%). All the ECG algorithms lose sensitivity for the critical non occlusive lesions group. Conclusions Patients with acute myocardial infarction and LBBB present distinct patterns of QRS and ST segment changes and different diagnostic yielding of ECG algorithms in relation to the location of the occluded coronary artery. Data suggest that ECG prediction of the culprit coronary artery in patients with AMI and LBBB might be possible using artificial intelligence systems in larger series of patients. Funding Acknowledgement Type of funding sources: None.