Ischemic CVA Research Articles

Braden Scale in pressure ulcer risk assessment.

To analyze the applicability of the Braden Scale to individuals admitted to an Intensive Care Unit (ICU) with the nursing diagnosis Impaired Physical Mobility, in its prediction potential to develop pressure ulcer (PU). A cross-sectional, quantitative study that evaluated all patients hospitalized in an ICU between November 2016 and February 2017, with the Braden Scale. The prevalence of PU was 35.8% (24/67), in male individuals 58.3% (14/24), diagnosed with ischemic CVA 51.9% (12/27), and with hemorrhagic CVA 7.4% (2/27). Among patients classified at severe risk of developing pressure ulcer, 83.3% (20/53) developed it, and 76.7% (33/53) did not develop it. The performance of the Braden Scale showed a balance between sensitivity and specificity, confirming it as a better predictive risk assessment instrument in this group of patients.

NATIONAL OBSERVATIONS OF ISCHEMIC AND HEMORRHAGIC CEREBROVASCULAR ACCIDENTS (CVA) IN TAKOTSUBO CARDIOMYOPATHY

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM PURPOSE: Takotsubo Cardiomyopathy (TTC) or stress-induced cardiomyopathy has been speculated to increase the risk of stroke with literature suggesting an incidence ranging up to 7.7% in this population. TTC can occur as a cause or a complication of stroke (CVA) and the temporal relationship between the two events is often unclear. We sought to evaluate the incidence of ischemic vs hemorrhagic CVA in patients diagnosed with TTC. We also sought to assess the comorbidities serving as predictors, the demographics and health care utilization in these groups. METHODS: We queried the National Inpatient Sample (NIS) dataset from 2007 to 2014 to identify a diagnosis of TTC with the International Classification of Disease (ICD) Code 429.83. We then identified the two groups: patients without CVA and those with CVA which was further divided into ischemic CVA with ICD codes 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434x, 436x and hemorrhagic CVA with ICD codes 430.x, 431x, 432x. Multivariate and Chi-square analysis were done by using the statistical software, SAS. RESULTS: A total of 154,880 cases of TTC were diagnosed from the year 2007 to 2014 in the United States, with a 4.3% incidence of CVA with ischemic being 64% of total CVA. Mortality was higher in hemorrhagic CVA patients than ischemic (23.5% vs 16.1%, p < 0.05). Patients with ischemic CVA were more likely to have hypertension (65.3% vs 56.8% p<0.05), renal failure (10.6% vs 6.8% p<0.05) and diabetes (20.3% vs 11.5% p<0.05) than hemorrhagic CVA. There was almost a two-fold rise in patients with Valvular disease in those with both ischemic and hemorrhagic CVA than no stroke (10% vs 9.4% vs 4.6% p<0.05). Interestingly, a higher incidence of hypothyroidism was seen in patients without CVA than those with ischemic and hemorrhagic CVA respectively (17.7% vs 12.7% vs 9.48% p<0.05). Coagulopathy was more associated with hemorrhagic CVA than without CVA (23.6% vs 4.08% p<0.05). Length of stay and cost were higher in both types of CVA. There was an increased proportion of males developing ischemic and hemorrhagic CVA than those without CVA (17.4% and 19.7% vs 12.9% p<0.05). CONCLUSIONS: TTC was associated with a higher incidence of ischemic CVA than hemorrhagic. Preexisting cardiac risk factors were more associated with development of stroke. This included hypertension, diabetes and renal failure. Although females were more likely to have TTC, the proportion that developed CVA dropped in comparison. Outcome measures were worse in hemorrhagic stroke, likely attributed to the disease process itself. CLINICAL IMPLICATIONS: It is prudent to believe an increased risk of stroke in TTC, calling for further prospective trials to evaluate the predictors. By identifying at-risk populations, targeted interventions such as anti-platelet therapy, tighter glycemic control, may be used. DISCLOSURES: No relevant relationships by Ayesha Azmeen, source=Web Response No relevant relationships by ayesha shaik, source=Web Response No relevant relationships by Varun Tandon, source=Web Response

Dual antiplatelet treatment in TIA and high-risk ischemic CVA, a review of the POINT trial

Dual antiplatelet treatment in TIA and high-risk ischemic CVA, a review of the POINT trial

Serum Uric Acid Level as a Predictive Marker in Acute Ischemic CVA

Serum Uric Acid Level as a Predictive Marker in Acute Ischemic CVA

Abstract WP442: Cause of Death After Intracerebral Hemorrhage in the Longitudinal Follow-up of ICH Survivors in ERICH (ERICH-L) Study

Introduction: Anticoagulant therapy after intracerebral hemorrhage (ICH) in patients with atrial fibrillation or deep vein thrombosis has been associated with a marked reduction of death. Prevention of ischemic stroke could explain this reduction. We sought to describe the causes of death after discharge and beyond 30 days in a longitudinal follow-up of a multi-racial/ethnic cohort of ICH. We hypothesized that recurrent ICH and ischemic stroke are the most common cause of death after ICH. Methods: The Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) Study was a prospective, multi-center, case-control study of ICH among whites, blacks, and Hispanics. Subjects previously in the ERICH study were approached for enrollment in the Longitudinal Follow-up of ICH Survivors (ERICH-L) study. A standardized research interview was completed over the phone and 959 contacts were made with participants and surrogates to capture outcomes of interest at 6-month intervals, including information on ICH recurrence, ischemic stroke, cognitive performance, and cause of death. The median follow-up was 4.3 years with an IQR of 3.2-5.4. The cause of death categories were ICH, cardiac, ischemic CVA, other, cancer, pulmonary, renal, endocrine, accidents, infection, dementia and unknown. Results: There were 180 deaths (18.8%) reported by surrogates contacted in the ERICH-L study. Of those, 63 causes of death were unknown or considered unverifiable. The most common cause of death reported was decline from the index ICH (32.7%). The next most common cause of death was cardiac (14%), other (12.1%), infection (11.2%), cancer (10.3%) and ischemic stroke (1.9%). Some examples reported as other are liver failure, old age, myelodysplastic syndrome, suicide and Parkinson’s Disease. Recurrent ICH occurred in 4 out of 107 known causes of death. By year 5, cardiac causes surpassed ICH as the cause of death. Conclusion: Cardiac causes of death were more common than either recurrent ICH or ischemic stroke, surpassed only by decline from the index ICH. Future efforts to prevent causes of death after ICH should address cardiac disease and risk factors. This finding may explain the effect of restarting anticoagulant or antiplatelet therapy and improved mortality.

Identification of candidates for PFO closure in the echocardiography laboratory.

A patent foramen ovale (PFO) is implicated in several pathologic processes, including that of cryptogenic stroke (cCVA). Recent trials identify "high-risk" PFOs in patients with cCVA as likely to benefit from percutaneous closure. The younger the patient (<60years old) the more likely a PFO may be attributable to the cCVA. The RoPE Score index helps determine the likelihood that an existing PFO is related to a cCVA. This may help guide the clinician and patient when contemplating percutaneous PFO closure. When evaluating a patient for possible percutaneous closure, one should identify the CVA as a typical ischemic type stroke. In order to "rule-out" other causes of CVA, imaging of the intracranial arteries, cervical, and aortic arch vessels should be performed. Small vessel disease or a lacunar-type infarct should be excluded. To rule out atrial fibrillation, prolonged monitoring should be performed. An index has been developed to determine the probability that a PFO is the causative etiology and calculates the risk of recurrence. This may help guide the clinician and patient in the decision for PFO closure. In addition, one should consider a work-up for a hypercoagulable state. We will obtain an ultrasound of the lower extremities or consider deep pelvic vein thrombosis (prolonged sitting or malignancy). If the closure is to be performed, the Food and Drug Administration (FDA) has approved the Amplatzer PFO Occluder and the GORE Cardioform Septal Occluder for percutaneous closure. These devices are both approved in patients predominately between ages 18 and 60years with a cCVA due to presumed paradoxical embolism as verified by a neurologist and cardiologist and when other causes of ischemic CVA have been excluded. "High-risk" PFOs appear to achieve the most potential benefit from percutaneous closure.

A study of outcome of patients with ischemic CVA in relation to carotid lesions

A study of outcome of patients with ischemic CVA in relation to carotid lesions

Early Low Level Hemolysis Is Associated with Subsequent Device Thrombosis and Ischemic Stroke during Continuous Flow Left Ventricular Assist Device Support By the Heart Mate II

Background: Heart failure affects more than 7 million people in the United States with over 250,000 patients in advanced stages with a dismal 1 year survival of less than 20%. For such patients, mechanical circulatory support (MCS) with continuous flow left ventricular assist devices (CF LVADs) and 1-year survival rates of >80%, has become a viable treatment option, either as a bridge to heart transplantation or as destination therapy. Although bleeding is a known major problem during CF LVAD support, a more devastating sequela is the rising incidence of thrombosis. The etiology of thrombosis remains uncertain. Hemolysis is associated with a prothrombotic state in patients with paroxysmal nocturnal hemoglobinuria and in individuals with hemoglobinopathies, and is a significant complication of CF LVADs. We hypothesized that early low level hemolysis, as assessed by LDH at the time of discharge, could be related to subsequent thrombosis and might serve as a predictive biomarker.Methods: A retrospective single center review of all patients supported for at least 30 days by a Heart Mate (HM) II CF LVAD from January 2010 to July 2015 was conducted. All patients were on the same a priori antithrombotic regimen of aspirin 325 mg daily and warfarin therapy with a target INR of 2-3. Major demographics and LDH levels from the time of discharge of the HM II implant hospitalization were retrieved. Present, but low level hemolysis was defined by LDH levels of >400 U/L (normal range: 125-305 U/L). Cumulative survival free from a combined endpoint of confirmed device thrombosis and ischemic stroke (iCVA) was compared by using Kaplan Meier analysis. Device thrombosis was suspected by aberrant device parameters/malfunction and confirmed by device inspection after surgical exchange. Ischemic CVA was suspected based on neurologic symptoms and confirmed on Brain CT scan.Results: Overall, 123 patients were supported for 428±347 days by the HM II. Twelve (9.7%) had a thrombotic event from either a confirmed device thrombus (n=6) or an iCVA (n=6). There were no significant differences in age (thrombosis: 48±13yrs, no thrombosis: 54±12yrs, p=0.1) and gender (thrombosis: 16% female, no thrombosis: 23% female, p=0.9). Patients with thrombosis had a higher LDH at discharge (504 ±307 U/L) in comparison to those without thrombosis (350 ±110 U/L, p<0.0001). Patients with a LDH >400 U/L (n=88) at discharge had an over 6-fold higher risk of subsequent device thrombosis or iCVA in comparison to those with LDH levels ≤400 U/L (n=35, HR: 6.2, 95% CI: 1.7-22.3, p=0.002, Figure 1). Despite salvage interventions after thrombosis such as device exchange or heart transplantation, there was a trend towards worse overall survival in patients with a discharge LDH >400 U/L (HR: 1.5, 95% CI: 0.92-2.5, p=0.07).Conclusion: Low level hemolysis, as assessed by increased LDH levels at discharge during HM II support, is associated with thrombosis. Further studies to evaluate LDH as a predictive marker for thrombosis and investigations into the mechanisms of a hemolysis-induced pro-thrombotic state during CF LVAD support are warranted. [Display omitted] DisclosuresGoldstein:St. Judes Medical: Consultancy. Jorde:St. Judes Medical: Consultancy.

Is there any relationship of age & sex to the etiology and outcome of medical coma?

As the diseases behave differently in males and females and even in different age groups, particular attention was made to classify and observe the distribution of various causes of coma according to age and sex of the patient in order to formulate our indigenous database for future reference. We studied the coma etiology with particular reference to the age and sex of the patient, and the outcome. All the 517 (312 male {60.35%} and 205 female {39.65%}) patients were divided into 7 groups according to decades from age 12 to 80 years. Patients older than 40 years predominated (318 {61.5%}). Metabolic coma was predominant cause in almost all age groups. Structural coma was increasing progressively with the age. Poisonings were the common cause in patients under 30, representing 35.85% of all comas in the age group 12-20, and 33.70% in the group from 21-30 years. In the next two decades (31-50 years), hepatic and renal failure predominated making up more than half of all causes. Leading causes among males we re poisonings (69 cases), hemorrhagic CVA (48 cases), ischemic CVA (24 cases), renal failure (28 cases) and hepatic coma (35 cases). Similarly among females causal distribution revealed renal failure (34 cases), followed by hepatic coma (29 cases), and hemorrhagic CVA (26 cases). Out of the 476 (92%) patients whose outcome could be determined 297 (57.4%) were discharged after recovery and 179 (34.6%) died. Eighty out of 205 female patients died (39%), while 99 out of 312 males had a fatal outcome (31.7%). We conclude that coma etiology has a significant effect on prognosis, while such significance could not be assigned to age or sex.

Prevalence of hypertension and risk factors among school children in Kerala, India

Background: Early diagnosis of hypertension in childhood is an important strategy in its control and hypertension may begin in childhood, perhaps even in infancy. The objective of the study was to To know the prevalence of hypertension and risk factors among school going children between 5 – 10 yrs of age in Thrissur District, Kerala India. Methods: 1610 school children of the age group 5-10 years from 6 schools of rural and urban regions were selected by purposive sampling method. They were subjected to anthropometric measurements after getting informed consent. Blood pressure measurements were taken using mercury sphygmomanometer as per recommendation. Hypertension is considered when blood pressure is more than 95th percentile adjusted for age and gender based on BP percentile charts. Results: Total prevalence of hypertension in this study was 4.5% and Pre-hypertension is 5.8 %. Urban school children with hypertension were 7.52% against rural were 1-2% , pre hypertension in urban school children were 9.4% ,rural 1.84% Hypertension in males were 4.31% and in females were 4.65% Prevalence of obesity in hypertension was 11 .32% against normotensive 4.61% (P <0.05). Prevalence of hypertension in children with family history of hypertension, diabetes was high and statistically significant. Conclusions: We found childhood obesity, family history of diabetes mellitus ischemic heart disease and CVA had strong association with childhood hypertension. Awareness of hypertension was very low. Periodic measurements should be done in schools to identify the high risk group of children and adolescents who can develop hypertension.

Increased carotid intima–media thickness predicts cardiovascular events in aortic coarctation

BackgroundAdult post-coarctectomy patients (CoA) demonstrate increased cardiovascular morbidity and mortality. The carotid intima–media thickness (CIMT), a marker for atherosclerosis, is increased in CoA. The aim was to evaluate the predictive value of CIMT for cardiovascular events. Methods and resultsConsecutive CoA patients were prospectively studied during 10.1±0.7years follow-up. At baseline and follow-up echocardiography, MRI imaging and CIMT imaging were performed, while cardiovascular events were registered. CIMT data were compared with controls. The composite endpoint included: myocardial infarction, cerebrovascular events (CVAs), and (sudden) cardiac death. 160 CoA patients were studied (median age 31.7 (18–74years), 64% male). Events occurred in 11 patients (7%), five (3%) with myocardial infarction, four (2.5%) with an ischemic CVA and two (1%) died suddenly. An increased CIMT (≥0.8mm) (HR=15.44, P=<0.001) was predictive for the occurrence of cardiovascular events. Baseline CIMT was increased in CoA compared to controls (0.64±0.12mm vs 0.57±0.07mm, P=0.005). CIMT progression rates were similar (0.0091±0.016mm/year vs 0.0097±0.018mm/year, P=0.84). Signs of atherosclerosis occurred significantly earlier in CoA patients. ConclusionThe contemporary cardiovascular event rate in CoA is 11% in 10years. Atherosclerosis seems to appear earlier in CoA patients as compared to controls. CoA patients with a CIMT exceeding 0.8mm have a fifteen fold higher cardiovascular risk. CIMT seems to be a useful tool for cardiovascular risk assessment in CoA.

English

Stroke is the leading cause of mortality worldwide. Carotid Intima Media Thickness (CIMT) is a marker of atherosclerosis and is also a marker for ischemic stroke. AIMS: 1) To assess the value of carotid intima media thickness at which patients with risk factors can develop acute ischemic stroke. 2) To correlate carotid intima media thickness with risk factors of acute ischemic stroke. MATERIAL & METHODS: This study was done at KIMS Hospital, Bangalore between December 2010 to September 2012. This is a case control observational study which has a sample size of 50 cases and 50 controls. Method of collection of data was by patient evaluation which was done by taking detailed history, clinical examination and laboratory investigations through a proforma specially designed for this study. Cases were subjects who had ischemic stoke and Infarct proven by CT/MRI of brain, Controls were subjects without stroke matched to cases by age, gender and risk factors like diabetes, hypertension, smoking and dyslipidemia. Subjects in both groups underwent carotid Doppler investigation with 7.5 Mhz linear superficial array probe to determine CIMT and presence of plaques. RESULTS: Out of 50 cases, 46 had CIMT between 0.06-0.20 cm (92%) and out of 50 controls, 45 had CIMT between 0.06-0.20 cm(90%). Most of our cases had CIMT above 0.06 cm, so we can hypothesize that people with risk factors having CIMT above 0.06 cm are more prone for ischemic cerebro vascular accidents. Mean CIMT in cases with risk factors is significantly increased when compared to controls with risk factors. CONCLUSION: People with risk factors ( age > 50 years, DM , HTN , Smoking and Dyslipidemia) having CIMT above 0.06 cm are more prone for ischemic CVA, so people with risk factors should u ndergo screening for CIMT measurement by Carotid Doppler which is non invasive and cost effective and if their CIMT is above 0.06 cm they should undergo early medical intervention to take care of risk factors and lifestyle modifications, so that they can be prevented from ischemic CVA in future.

A meta‐analysis of transcatheter closure of patent foramen ovale versus medical therapy for prevention of recurrent thromboembolic events in patients with cryptogenic cerebrovascular events

We sought to perform a meta-analysis of randomized controlled trials (RCTs) comparing percutaneous patent-foramen-ovale (PFO) closure with medical therapy for preventing recurrent thromboembolic events after cryptogenic stroke. Observational studies suggested that transcatheter PFO closure decreases recurrent events after cryptogenic stroke; however, three recent RCTs failed to demonstrate such benefit. Trials were identified from the PubMed and Cochrane databases. Primary endpoint was the composite of transient ischemic attack (TIA) and ischemic cerebrovascular events (CVA). Both intention-to-treat (ITT) and as-treated analyses (AT) were performed. Three RCTs met inclusion criteria. The pooled data provided 2,303 patients, of which 1,150 were in the PFO closure group and 1,153 in the medical therapy group. In the ITT analysis, there were 43 events (3.7%) of the composite end point in the closure group compared with 61 events (5.3%) in the medical therapy group, with a trend in favor of the PFO closure (OR = 0.70; 95% CI, 0.47-1.05, P = 0.08). The incidences of TIA, ischemic CVA, and bleeding were not statistically different between the groups. There was a trend for the more frequent occurrence of atrial fibrillation in the PFO closure group (OR = 3.29; 95% CI, 0.86-12.60, P = 0.08). In the AT analysis, the composite end point was significantly less frequent in the PFO closure group (OR = 0.62; 95% CI, 0.41-0.94, P = 0.02). In this meta-analysis of contemporary RCTs, successful transcatheter closure of PFO might be more effective than medical therapy alone for the prevention of recurrent thromboembolic events.

Breakthrough Stroke During Rivaroxaban Therapy in a Patient with Non-Valvular Atrial Fibrillation

Abstract 4370 Introduction.Rivaroxaban is the first orally active direct factor Xa inhibitor FDA approved for anticoagulation in non-valvular atrial fibrillation. Rivaroxaban has several remarkable aspects-it has less incidence of fatal bleeding and intracranial hemorrhage compared to Warfarin, excellent pharmacodynamic profile as an oral agent (high bioavailability (80–100%) and short half-life (7 to 11 hours), and it is reversible- which highlights Rivaroxaban as a promising future anticoagulant. However, 1.71% of Rivaroxaban arm in ROCKET-AF (New Eng J Med 2011;365:883-91) trial developed breakthrough stroke or systemic embolism while on therapeutic dose. We present the first report of breakthrough stroke in a patient with non-valvular atrial fibrillation anticoagulated with Rivaroxaban. Case presentation.A 52-year-old Caucasian male with non-valvular atrial fibrillation presented with aphasia, right-sided weakness and right facial droop. The patient was newly started on Rivaroxaban for two weeks followed by successful elective cardioversion a day prior to admission. One hour prior to admission, the patient was found with global aphasia, right hemianopsia and hemiparesis consistent with left MCA stroke. Ischemic CVA was confirmed with non-contrast CT. The patient underwent emergent cerebral angiogram and successful mechanical thrombolysis (Solitaire) of left MCA embolus. A week later, neurologic condition improved to hemiparetic and independent gait with residual dysarthria and right facial droop. Given his breakthrough embolic event, the choice of anticoaulgation was changed to Dabigatran. Conclusion.We have demonstrated the first case of breakthrough stroke while on therapeutic dose of Rivaroxaban in a patient with non-valvular atrial fibrillation. In a subset of patients with ischemic stroke while on therapeutic doses of oral anticoagulants, mechanical thrombolysis is crucial and intravenous thrombolytics should be avoided to minimize risk of intracranial hemorrhage. The effectiveness of alternative anticoagulation after failing Rivaroxaban needs to determined with further studies. Disclosures:No relevant conflicts of interest to declare.

Intertrochanteric fractures in elderly high risk patients treated with Ender nails and compression screw.

Background:Ender and Simon Weidner popularized the concept of closed condylocephlic nailing for intertrochanteric fractures in 1970. The clinical experience of authors revealed that Ender nailing alone cannot provide secure fixation in elderly patients with osteoporosis. Hence we conducted a study to evaluate the efficacy of a combined fixation procedure using Ender nails and a cannulated compression screw for intertrochanteric fractures.Materials and Methods:76 patients with intertrochanteric fractures were treated using intramedullary Ender nails and cannulated compression screw from January 2004 to December 2007. The mean age of the patients was 80 years (range 70-105 years).Using the Evan’s system of classification 49 were stable and 27 unstable fractures. Inclusion criteria was high risk elderly patients (age > 70 years) with intertrochanteric fracture. The exclusion criteria included patients with pressure sores over the trochanteric region. Many patients had pre-existing co-morbidities like diabetes mellitus, hypertension, COPD, ischemic heart disease, CVA and coronary artery bypass surgery. The two Ender nails of 4.5mm each were passed across the fracture site into the proximal neck. This was reinforced with a 6.5 mm cannulated compression screw passed from the sub trochanteric region, across the fracture into the head.Results:The mean follow-up was 14 months (range 9-19 months) Average time to fracture union was 10 weeks (range 6-16 weeks). The mean knee ROM was 130° (± 5°). There was no case of nail penetration into hip joint. In five cases with advanced osteoporosis there was minimal migration of Ender nails distally.Conclusions:The Ender nailing combined with compression screw fixation in cases of intertrochanteric fractures in high risk elderly patients could achieve reliable fracture stability with minimal complications.

Solitary fibrous pleural tumor associated with loss of consciousness due to hypoglycemia

The patient suffered loss of consciousness, dysarthria and right sided hemiparesis. The CT scan and MRI scans were negative. These findings are more in keeping with a diagnosis of Transient Ischemic Attack (TIA) or mild CVA. Hypoglycemia per se does not usually cause hemiparesis. The blood glucose level was low but I am not sure if one can conclude that hypoglycemia caused the above noted neurological signs and symptoms. The authors do not present any data to prove that this patient had "hypoglycemic coma".

Atherothrombosis: Environmental links

During the past decades, many studies were published considering cosmo-terrestrial influences on different sites of human homeostasis. The aim of this study was to summarize some of those studies in the field of cardiovascular medicine, concentrating on environmental physical activity--Solar (SA), Geomagnetic (GMA), and conversely, Cosmic Ray (CRA)--links with atherothrombosis, the basic mechanism of most vascular catastrophes in modern society. A preview of a number of comparative studies between clinical events-acute myocardial infarction (AMI), sudden cardiac death (SCD), stroke (CVA), laboratory data of coagulation, inflammation (daily, monthly), with parameters of SA, GMA, CRA, and closely linked to CRA, high energy space proton flux at high energies. The clinical and laboratory data were from studies in Lithuania and Israel. The physical data were from space-science institutions in the USA and Russia (until 1990-USSR). Student's t-test and Pearson correlation coefficients and their probabilities were used. A significant relation was found between the level of GMA (I-IV) and blood coagulation parameters, (platelet count and aggregation, fibrinogen, INR [ratio of patient's prothrombin time to normal], inflammation markers--serum C-reactive protein (CRP), elements of anti-phospholipid syndrome, number of deaths from ischemic CVA, SCD, outpatients death from AMI. The monthly occurrence of AMI (total and all subtypes) was connected with CRA. Monthly deaths from CVA (mostly ischemic) were correlated with CRA, and both events were closely connected with atherothrombosis. Three basic components of atherothrombosis-blood coagulation, inflammation, atheroma disruption are connected with environmental physical activity--CRA is predominant in plaque disruption, cellular damage, electrical instability, GMA in the activation of coagulation and inflammation.

983 Does transesophageal echocardiography influence the treatment of young patients with cryptogenic TIA or ischemic CVA?

983 Does transesophageal echocardiography influence the treatment of young patients with cryptogenic TIA or ischemic CVA?

4g/5g Prevalence in 223 Patients with Thrombosis and in 162 Healthy Controls, from the Centre Region of Portugal.

A deletion/insertion polymorphism (4G or 5G) in the promoter of the PAI-1 gene has been suggested to be involved in regulation of the synthesis of the inhibitor, the 4G allele being associated with enhanced gene expression, and therefore related with thrombosis. In the present work we studied the prevalence of 4G/5G polymorphism in 223 unrelated patients with history of objectively confirmed thromboembolism, and in 162 healthy unrelated controls, both groups natural from all centre regions of Portugal. In this normal cohort, the prevalence of 4G/4G is 23%, 4G/5G is 38% and 5G/5G is 39%; in the affected population is, respectively, 47%, 21.5% and 30%, which means that 4G/4G is twice more frequent in the patients with thrombosis. When we relate the age of the first thrombosis episodes in the three groups, we find no significative difference, as the respective media is 36.8; 38.6 and 35.5 years in the 4G/4G, 4G/5G and 5G/5G group, respectively. This data suggest that this polymorphism by itself, even in homozygosity, is not associated with earlier thrombosis. In our patients, we studied the presence of Lupus Anticoagulant, Factor V Leiden, Factor IIG20210A, MTHFR C677T, and also Antithrombin III, Protein S and Protein C levels. We analyse the prevalence of the three mutations in patients with DVP, PTE, ischemic and venous CVA and we only find a significative difference in the 4G/4G group: 46.2% patients with DVP and 48.2% patients with PTE (23% in normal cohort). In conclusion, in the centre region of Portugal, the prevalence of 4G/4G is 23%, 4G/5G is 38% and 5G/5G is 39%; in our cohort of unrelated patients the only significative difference is in the 4G/4G group (47%); this variation maintain in the DVP and PTE group. We did not find difference at the age of the first thrombotic episode, in the three groups.

Perception and production of facial and prosodic emotions by chronic CVA patients

Variable etiology, limited testing of emotions and inclusion of patients in acute and chronic phases have made it difficult to specify the extent of right hemisphere involvement in the processing of emotional material. In addition, there is an absence of data concerning CVA patients’ long-term abilities to process emotional information. Two groups of subjects with unilateral brain damage (15 RBD, 17 LBD), matched for chronicity (minimum 12 months post-CVA), etiology (ischemic CVA), duration of hospitalization and other variables, and an appropriate control group participated in two experiments to address these concerns. In the first experiment, subjects were given a series of tasks (discrimination, identification, imitation, production on request) to assess their processing of facial expressions of the six universal emotions [P. Ekman, W. Friesen, Unmasking the face, Prentice-Hall, Englewood Cliffs, 1975]. The results showed that three emotions (surprise, happiness, fear) discriminate between RBD and LBD patients and controls, with RBD subjects performing worse than the other groups on the identification task only. Using tasks of the same nature, the second experiment investigated the processing of emotional prosody. The results showed that three emotions (fear, sadness, anger) discriminate between RBD and LBD patients and controls, with RBD subjects again performing worse than the others on the discrimination, imitation and production on request tasks. LBD subjects performed as well as normal controls on almost all tasks. The RBD subjects were the only ones who showed relatively consistent impairment in the processing of both facial and prosodic emotional information. Taken together, these data strongly suggest that the right hemisphere is preferentially involved in processing emotional information in the chronic phase of brain damage.