Ischemic Manifestations Research Articles

Intraplaque CTA characteristics as predictors of symptomatology: a semiautomated volumetric analysis.

Prior studies comparing CT characteristics of carotid plaques to symptomatology have relied on gross morphologic imaging features. This study sought to determine if volumetric measurements of carotid plaque components are associated with ipsilateral neurologic symptoms. CTA images of consecutive patients that underwent a carotid endarterectomy were reviewed with a semiautomated software package. Intraplaque volumes of intraplaque hemorrhage (IPH), lipid-rich necrotic core (LRNC), and matrix were computed, as was the degree of arterial stenosis. Statistics were analyzed on a per cerebral hemisphere basis, and dichotomized into symptomatic and asymptomatic. Clinical and radiological endpoints included transient ischemic attack (TIA), ischemic stroke diagnosed on imaging studies, ophthalmologically diagnosed central or branch retinal artery occlusion (RAO), or amaurosis fugax. One hundred sixty-eight carotid plaques were reviewed. The average age is 70.8years (SD = 8.8); 32/87 (36.8%) were female. Sixty-seven of eighty-seven (77.0%) patients were symptomatic. Sixty-six of one hundred sixty-eight (39.3%) plaques were ipsilateral to the patient's symptoms, while 102/168 (60.7%) were ipsilateral to an asymptomatic hemisphere. Greater intraplaque volumes of IPH (p = 0.03), LRNC (p = 0.008), and matrix (p = 0.0008) were associated with symptoms, as was greater proportion of LRNC in regard to plaque volume (p = 0.04). All but proportion of LRNC remained statistically significant after adjustment for plaque size. More severe luminal stenosis was also associated with ipsilateral neurologic symptoms, both when calculated by smallest diameter or by area (p < 0.0001 for both). Higher volumes of intraplaque IPH, LRNC, matrix, and degree of arterial stenosis are associated with ipsilateral neurologic symptoms. Greater intraplaque proportions of LRNC are also associated with ipsilateral ischemic manifestations, suggesting that larger relative composition of lipids may be particularly predictive of symptomatology.

Стресс и качество жизни после перенесенной транзиторной ишемической атаки

Актуальность. Преходящие ишемические атаки являются одним из вариантов развития острых нарушений мозгового кровообращения и занимают значительное место среди патологии нервной системы. В качестве осложнений они характерны для течения гипертонической болезни. В клиническом течении атак отсутствует визуализация очагов поражения мозга и наблюдается инволюция неврологической симптоматики в течение 24 часов. Преходящие ишемические атаки являются неотложным состоянием, вызывают значительную стрессовую реакцию личности, которая оставляет после себя изменения в психической сфере. Исследование этих факторов крайне недостаточно, хотя они имеют большой вес для прогноза и проведения своевременной адекватной психокоррекции в составе профилактики развития повторных ишемических проявлений. Цель: работа направлена на изучение характеристик воздействия на сферы личности стрессового состояния после перенесенной транзиторной ишемической атаки у больных гипертонической болезнью и способов их психокоррекции. Материалы и методы. В исследовании принимали участие 114 больных гипертонической болезнью II–III стадии в возрасте от 55 до 65 лет, среди которых 59 перенесли транзиторную ишемическую атаку с госпитализацией. Протокол исследования был составлен в соответствии с Хельсинкской декларацией. Исследование проведено в амбулаторных условиях через 30–45 дней после выписки из больницы. Для обследования применяли клинико-патологическое исследование, психодиагностическое исследование с использованием методик: шкала Спилбергера — Ханина для определения тревожности, тест «Диагностика копинг-стратегий Хайма», опросник качества жизни Всемирной организации здравоохранения. Результаты обрабатывались статистическими методами с вычислением достоверности. Результаты. После перенесенной транзиторной ишемической атаки у больных обнаружили признаки хронического психического стресса, что подтверждалось высокими уровнями реактивной и личностной тревожности. Установлено, что в результате перенесенной транзиторной ишемической атаки у пациентов менялись копинг-стратегии в сторону уменьшения степени адаптивности. Больше изменялись эмоциональные, а за ними — когнитивные стратегии, что выражалось в появлении непродуктивных и слабопродуктивных способов реагирования. На этом фоне наблюдали увеличение продуктивных поведенческих стратегий. У больных также наблюдалось снижение качества жизни в большинстве сфер. Возможно, это было следствием хронического психического стресса перед угрозой повторного приступа и инсульта, наличием дезадаптации из-за необходимости изменений поведения и образа жизни. К этому приводили внутреннее сопротивление, разрушение привычных стереотипов и отсутствие соответствующих стратегий компенсаторного поведения. Установлена повышенная значимость показателей качества жизни, особенно личностного характера, что связано с ограничениями из-за наличия болезни. Проведение индивидуальной психокоррекции после транзиторной ишемической атаки позволило достичь значительных результатов в улучшении адаптации пациентов.

Imaging Tests in the Early Diagnosis of Giant Cell Arteritis.

Early recognition of giant cell arteritis (GCA) is crucial to avoid the development of ischemic vascular complications, such as blindness. The classic approach to making the diagnosis of GCA is based on a positive temporal artery biopsy, which is among the criteria proposed by the American College of Rheumatology (ACR) in 1990 to classify a patient as having GCA. However, imaging techniques, particularly ultrasound (US) of the temporal arteries, are increasingly being considered as an alternative for the diagnosis of GCA. Recent recommendations from the European League Against Rheumatism (EULAR) for the use of imaging techniques for large vessel vasculitis (LVV) included US as the first imaging option for the diagnosis of GCA. Furthermore, although the ACR classification criteria are useful in identifying patients with the classic cranial pattern of GCA, they are often inadequate in identifying GCA patients who have the extracranial phenotype of LVV. In this sense, the advent of other imaging techniques, such as magnetic resonance imaging (MRI), computed tomography (CT), and positron emission tomography (PET)/CT, has made it possible to detect the presence of extracranial involvement of the LVV in patients with GCA presenting as refractory rheumatic polymyalgia without cranial ischemic manifestations. Imaging techniques have been the key elements in redefining the diagnostic work-up of GCA. US is currently considered the main imaging modality to improve the early diagnosis of GCA.

Synthesis of the Data on COVID-19 Skin Manifestations: Underlying Mechanisms and Potential Outcomes.

The incidence of coronavirus disease 2019 (COVID-19)-related skin manifestations has progressively grown, in parallel with the global severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spreading. The available evidence indicates that cutaneous signs are heterogeneous and can be divided as follows: a) erythematous rashes, b) lesions of vascular origin, c) vesicular rashes, d) urticarial rashes, and e) acute generalized exanthematous pustulosis (AGEP), erythema multiforme (EM) and other polymorphic/atypical reactions. Most cutaneous manifestations appear simultaneously or after respiratory and/or systemic symptoms such as fever, even if rarely urticaria has been reported as the first sign of the disease. It has been proposed that erythematous and vesicular rashes, as well as urticaria, are the result of immunological activation against Sars-CoV-2, similarly to other viral exanthems; alternatively, reactivation or co-infection of herpesviruses and drug hypersensitivity represent possible etiologic diagnosis that has to be considered. Regarding lesions of vascular origin, ischemic ones are the result of systemic hypercoagulability established in severe infections, whereas chilblains seem to be linked to the type I-interferon massively produced to halt virus replication. AGEP is triggered by drugs, whereas EM could represent a delayed immune response to the virus or a hypersensitivity reaction to drugs elicited by the inflammatory process built to fight the infection. A further pathogenic hypothesis is that the virus, or its particles detected in the skin (particularly in endothelium and eccrine glands), could be responsible for certain skin reactions, including chilblains and EM. From the available data, it appears that chilblains are correlated with younger age and less severe disease, while ischemic manifestations occur in the elderly with severe infection. In conclusion, larger studies are needed to confirm the suggested pathogenetic mechanisms of COVID-19-related skin reactions and to determine the potential prognostic significance of each one.

Vascular endothelial growth factor haplotypes are associated with severe ischaemic complications in giant cell arteritis regardless of the disease phenotype.

To determine whether functional vascular endothelial growth factor (VEGF) polymorphisms influence the expression of the clinical phenotype of giant cell arteritis (GCA). We also evaluated whether VEGF polymorphism is associated with the development of severe ischaemic manifestations in patients with GCA regardless of the clinical phenotype, classic cranial GCA or predominantly extracranial GCA large vessel vasculitis (LVV). VEGF rs833061 T/C, rs2010963 G/C and rs3025039 C/T polymorphisms were genotyped in 185 patients with biopsy-proven cranial GCA, 105 with extracranial LVV-GCA and 490 healthy controls. Allelic combinations (haplotypes) of VEGF were carried out. Comparisons were performed between patients with GCA and healthy controls as well as between patients with GCA stratified according to the clinical phenotype and the presence of severe ischaemic manifestations. No significant differences in genotype, allele, and haplotype frequencies of VEGF were found between patients with GCA and healthy controls as well as between GCA patients with the classic cranial pattern and the extracranial LVV-GCA pattern of the disease. However, the VEGF CGC haplotype (OR= 1.63 [1.05-2.53]) and the CGT haplotype (OR= 2.55 [1.10-5.91]) were significantly more frequent in GCA patients with severe ischaemic complications compared to those patients without these complications. VEGF haplotypes seem to play a role in the development of severe ischaemic manifestations in GCA patients, regardless of the clinical phenotype of expression of the disease.

Development and Validation of a Nomogram to Predict the Individual Future Stroke Risk for Adult Patients With Moyamoya Disease: A Multicenter Retrospective Cohort Study in China.

Background: Studies exploring the predictive performance of major risk factors associated with future stroke events are insufficient, and a useful tool to predict individual risk is not available. Therefore, personalized advice for preventing future stroke in patients with moyamoya disease (MMD) cannot provide evidence-based recommendations. The aim of this study was to develop a novel nomogram with reliable validity to predict the individual risk of future stroke for adult MMD patients.Methods: This study included 450 patients from seven medical centers between January 2013 and December 2018. Follow-ups were performed via clinical visits and/or telephone interviews from initial discharge to December 2019. The cohort was randomly assigned to a training set (2/3, n = 300) for nomogram development and a test set (1/3, n = 150) for external validation. The Kaplan-Meier analyses and receiver operating characteristic (ROC) curves were applied to assess the clinical benefits of this nomogram.Results: Diabetes mellitus, a family history of MMD, a past history of stroke or transient ischemic attack, clinical manifestation, and treatment were identified as major risk factors via the least absolute shrinkage and selection operator (LASSO) method. A nomogram including these predictors was established via a multivariate Cox regression model, which displayed excellent discrimination [Harrell's concordance index (C-index), 0.85; 95% confidence interval (CI): 0.75–0.96] and calibration. In the external validation, the nomogram was found to have good discrimination (C-index, 0.81; 95% CI: 0.68–0.94) and calibration. In the subgroup analysis, this predictive nomogram also showed great performance in both ischemic-type (C-index, 0.90; 95% CI: 0.77–1.00) and hemorrhagic-type MMD (C-index, 0.72; 95% CI: 0.61–0.83). Furthermore, the nomogram was shown to have potential in clinical practice through Kaplan-Meier analyses and ROC curves.Conclusions: We developed a novel nomogram incorporating several clinical characteristics with relatively good accuracy, which may have considerable potential for evaluating individual future stroke risk and providing useful management recommendations for adult patients with MMD in clinical practice.

Vasculitis de mediano vaso. Vasculitis necrotizantes sistémicas. Panarteritis nudosa. Vasculitis ANCA positivas

Systemic necrotising vasculitis is a group of potentially serious inflammatory diseases of unknown aetiology, involving destructive inflammation of the vascular wall and mainly affecting the small and medium-sized vessels. Symptoms vary depending on the size and location of the affected vessels. Untreated, they are associated with high morbidity and mortality. Inflammation of the vascular wall causes obstruction of the vessel lumen with ischaemia and necrosis of the tissues it irrigates. We suspect the condition when several organ systems are affected simultaneously or consecutively, in the presence of a prolonged febrile syndrome or an unexplained toxic syndrome, ischaemic manifestations (skin ulcers, digital ischaemia) or other unusual clinical manifestations (mononeuritis multiplex, pulmonary infiltrates or nodules).When vasculitis is suspected, a detailed clinical history should be taken. In terms of laboratory tests, there are usually non-specific findings (anaemia, elevated ESR and C-reactive protein) that can be very striking, but do not differentiate vasculitis from other inflammatory or proliferative processes or, in many cases, renal failure. Treatment is based on the administration of glucocorticoids, combined or otherwise with immunosuppressive drugs and/or biological therapy, depending on its extent and severity.

COVID-19 with ischemic stroke manifestations

Background: Continuous pandemic caused by coronavirus disease (COVID-19) have been associated with high morbidity and mortality. COVID-19 has been linked to a hypercoagulable state that causes cerebrovascular complications. The most common cerebrovascular complication is ischemic stroke.Case Presentations: We report six cases of ischemic stroke with COVID-19, age 51-81 years old, consists of four males and two females. The main risk factors are hypertension and diabetes mellitus. Brain CT scan showed large vessel ischemic stroke in four patients. The patients were treated with Low Molecular Weighted Heparin followed by dual antiplatelet (aspirin and clopidogrel). The outcome was good recovery with minimal sequelae in four patients and death in two patients.Conclusion: Most of the stroke type in COVID-19 is large vessel disease, with main risk factors of hypertension and diabetes mellitus. Treatment with low molecular weight heparin (LMWH) followed by dual antiplatelet showed promising clinical improvement.

Systemic sclerosis is associated with lower limb vascular stiffness and microvascular impairment: results from a prospective study.

Systemic sclerosis (SSc) is a connective tissue disease characterized by microangiopathy. Peripheral arterial disease, increasingly studied during SSc, is responsible for digital ulcers, associated with a high risk of amputation. The aim of our study was to assess the frequency of lower limb arterial impairment in SSc patients by measuring ankle-brachial index (ABI), toe pressure (TP), and toe-brachial index (TBI). Systemic sclerosis patients were included prospectively during 1 year in Tenon and Saint-Antoine Hospitals, Paris. Clinical and biological data were recorded. For each patient, ABI, TP, and TBI were measured and an arterial duplex ultrasonography was prescribed in case of abnormal results. Eighty-six patients were included (94% women, median age 62 years). Only 24% of them had no lower limb hemodynamic vascular abnormalities; 44% had an isolated microvascular abnormality (normal ABI and TBI<0.75); 31% had at least a macrovascular injury associated or not with microvascular impairment (abnormal ABI) and 12.6% had a TP<50 mmHg. During follow-up, there was a trend towards association of low TBI with more major adverse event (all-cause mortality, non-fatal stroke, non-fatal myocardial infarction, and lower limb ischemic manifestations) than normal TBI. By measuring ABI and TP, we showed that 76% of SSc patients had hemodynamic arterial lower limb abnormalities related to macro- and/or microvascular impairment and that 28% had vascular stiffness. In SSc patients, ABI is not an accurate tool to detect lower limb arterial disease, likely due to underlying micro- and macrovascular changes. Key Points • The presence of lower limb macro-and/or microvascular involvement was detected in 76% of SSc patients. • In SSc patients, ABI is not an accurate tool to detect lower limb arterial disease, likely due to underlying microvascular changes and frequent arterial stiffness.

A Review of the Dermatological Complications of Giant Cell Arteritis.

Giant cell arteritis (GCA) is characterized by granulomatous inflammation of large and medium-sized vessels. It is the most common vasculitis among elderly people in Europe and North America. GCA usually presents with ischemic cranial manifestations such as headache, scalp tenderness, visual manifestations, and claudication of the tongue and jaw. Thickness and tenderness of temporal arteries are the most recognizable signs of GCA on physical examination. Laboratory tests usually show raised acute phase reactants. Skin manifestations are uncommon in GCA and are rarely found as a presenting symptom of GCA. Necrosis of the scalp and tongue is the most common ischemic cutaneous manifestation of GCA. Although infrequent, when present it reflects severe affection and poor prognosis of GCA. Panniculitis-like lesions have been reported in the setting of GCA, with nodules being the most common finding. Other entities, such as generalized granuloma annulare or basal cell carcinoma have been occasionally described in GCA patients. Prompt recognition and initiation of therapy are crucial to prevent serious complications of GCA. When high suspicion of GCA exists, immediate administration of glucocorticoids is recommended. It is advisable to refer the patient to a specialist GCA team for further multidisciplinary assessment.

Clinical Implications of the “Brush Sign” in Susceptibility-Weighted Imaging for Moyamoya Disease

Objective: Infarction is one of the most common postoperative complications after surgical revascularization for moyamoya disease (MMD). Increased conspicuity of deep medullary veins (DMVs) on susceptibility-weighted imaging (SWI), known as “brush sign,” could predict the severity of MMD. This study aimed to reveal the features of the “brush sign” in preoperative SWI and to verify its relationship to postoperative infarction. Methods: Consecutive patients with MMD who had undergone cerebral revascularization surgery were included. Routine preoperative SWI was performed. The “brush sign” was defined according to the number of the conspicuous DMVs > 5 detected on SWI. Postoperative infarctions were defined as the high-intensity signal on postoperative DWI images, with or without neurologic deficits. The modified Rankin scale (mRS) was applied to evaluate the prognosis of patients. Results: In the enrolled 100 hemispheres, 35 were presented with the “brush sign.” Patients with ischemic onset manifestation and previous infarction history tended to present with the “brush sign.” Multivariate analysis showed that the “brush sign” (OR 13.669; 95% CI, 1.747–106.967, p = 0.013) and decreased rCBF (OR 6.050; 95% CI, 1.052–34.799, p = 0.044) were independent risk factors of postoperative infarction. Besides, the “brush sign” showed a significant correlation with a higher mRS score at discharge (p = 0.047). Conclusion: The findings strongly suggest that the presence of the “brush sign” preoperatively can be a predictor of infarction after surgical revascularization for ischemic MMD. It may contribute to an improved surgical result through focused perioperative management based on appropriate surgical risk stratification.

COVID-19 vasculitis and novel vasculitis mimics.

COVID-19 has been occasionally linked to histologically confirmed cutaneous vasculitis and a Kawasaki-like vasculitis, with these entities generally having minimal or no lung involvement and a good prognosis. Unlike these vasculitis types, patients with severe COVID-19 pneumonia can develop cutaneous vasculitis-like lesions and systemic arterial and venous thromboemboli, including cryptogenic strokes and other vasculopathy features. Proposed underlying mechanisms for these severe manifestations have encompassed immune dysregulation, including an anti-phospholipid syndrome-like state, complement activation, viral dissemination with direct systemic endothelial infection, viral RNAaemia with immunothrombosis, clotting pathway activation mediated by hypoxaemia, and immobility. In this Viewpoint, we highlight how imaging and post-mortem findings from patients with COVID-19 indicate a novel thrombosis in the pulmonary venous territory distal to the alveolar capillary bed, a territory that normally acts as a clot filtration system, which might represent an unappreciated nidus for systemic microembolism. Additionally, we suggest that this mechanism represents a novel vasculitis mimic related to COVID-19 that might lead to cryptogenic strokes across multivessel territories, acute kidney injury with haematuria, a skin vasculitis mimic, intestinal ischaemia, and other organ ischaemic manifestations. This finding is supported by pathological reports of extensive pulmonary venular thrombosis and peripheral organ thrombosis with pauci-immune cellular infiltrates. Therefore, severe COVID-19 pneumonia with extensive pulmonary intravascular coagulopathy might help to explain the numerous systemic complications of COVID-19, in which the demonstration of direct organ infection has not adequately explained the pathology.

Safety and Effectiveness of a Shortened Regimen of Alprostadil (PGE1) with Large Infusion Dose, for Ischemic Manifestations of the Extremities in Real?World Clinical Practice

Objective: To analyse historical indications, tolerance, secondary effects and effectiveness of a treatment regimen with short interrupted cycles of large doses of PGE1 as well as possible factors that may influence the results in real world clinical practice in a tertiary hospital. Material and Methods: This is an observational, descriptive, retrospective study of all patients treated from 2013 to 2020 with high-doses of PGE1 in our hospital. Results: Forty five patients from 27 to 91 years old were treated for ischemic diseases, grouped into 6 types. Treatment caused side effects in 14 patients (31%) and has to be discontinued in 6 of them for intolerance (13% of total). Intolerance was associated with heart disease and advanced age. No short or long term complications were observed in these patients after discontinuation of treatment. Effectiveness was considered in 53.3% in mean, decreasing with age, more abruptly from 80 years old. Neither heart disease nor kidney disease, decreased effectiveness. Conclusion: Although side effects are relatively common, there is no morbidity associated with the high-dose in short cycles of alprostadil, with a considerable effectiveness in not elderly patients and thus, could be considered a useful tool in the treatment of severe non-surgical vascular pathology.

Analysis of the clinical manifestations of cerebral stroke in patients with the novel coronavirus infection (COVID-19)

Objective: To improve the diagnosis and treatment of acute cerebrovascular accident in patients with community-acquired pneumonia caused by the novel coronavirus infection (COVID-19). Materials and methods: For the first time, clinical manifestations of strokes in patients with diagnosed new coronavirus infection (COVID-19) were analyzed in 130 patients. The study was conducted in two groups. The main group consisted of 69,2 % (n = 90) with a clinical and instrumental diagnosis: novel coronavirus infection in combination with stroke. The control group (30,8 %; n = 40) included the cases of ischemic and hemorrhagic stroke without signs of SARS-CoV-2. In both groups, the severity of the disease and pathogenetic subtypes were compared, and the features of the laboratory biochemical data were studied. Statistical analysis of the outcomes was carried out taking into account the severity of brain and lung tissue damage. Results: In patients with cerebral stroke against the background of the new coronavirus infection (COVID-19), the prevalence of ischemic stroke cases (86,4 %) was noted for undetermined (41,4 %) and cardioembolic (35,7 %) pathogenetic subtypes (according to TOAST) with localization in the carotid basin (89,7 %). In hemorrhagic stroke, parenchymal hemorrhage was observed with a greater frequency (54,5 %). The severity of the diagnosed strokes according to the NIHSS scale was up to 13,16 (8,80) points with less severe brain damage — Glasgow coma scale (14,0 (12,0 15,0). In the group of the patients, a widespread lesion of the lung tissue was diagnosed in 82,2 % of cases. No significant increase in the incidence of clinically significant manifestations of systemic and organ hypercoagulation was established. Conclusions: In stroke patients with COVID-19, ischemic manifestations with undetermined and cardioembolic subtypes without age and gender features prevail, with no differences in the severity of the course and a large number of favorable outcomes. A high activity of inflammatory and infectious changes was established by clinical laboratory.

Systemic thromboembolism from a misdiagnosed non‑bacterial thrombotic endocarditis in a patient with lung cancer: A case report

Thromboembolic events are frequent in patients with cancer, commonly involving the venous and pulmonary circulation. The arterial system is rarely implicated in embolism and, when involved, a cardiogenic origin should always be excluded. In the present study, a case of a patient who developed multiple embolic events concomitantly with the diagnosis of locally-advanced non-small cell lung cancer with high expression levels of programmed death-ligand 1 (PD-L1) in >50% of tumor cells is reported. A cardiac defect interpreted as a patent foramen ovale required low molecular weight heparin administration. Despite the anti-coagulant therapy, before first-line anticancer treatment with pembrolizumab immunotherapy could be administered due to high PD-L1 expression levels, a new hospitalization was required due to the onset of novel ischemic manifestation. New transthoracic and transesophageal echocardiography revealed a previously misdiagnosed vegetation of the mitral valve that caused systemic embolization. The lack of any sign of infection led to the diagnosis of a non-bacterial thrombotic endocarditis (NBTE), whose embolic sprouting gave rise to the widespread ischemic events. No active anticancer treatment was feasible due to the rapid progression of the disease. NBTE can evolve quickly, eventually preventing any chance of treatment targeting the primary cause, which in the present study was lung cancer. If NBTE can be correctly diagnosed sooner then there may be the potential for anticancer therapy that does not worsen the hypercoagulability state, thus improving cancer-associated survival.

Nervous System Involvement in Coronavirus Disease 2019: Results from a Retrospective Consecutive Neuroimaging Cohort.

BackgroundNeurological complications in coronavirus disease 2019 (COVID-19) have been described, but the understanding of their pathophysiology and neuroanatomical correlates remains limited.PurposeTo report on the frequency and type of neuroradiological findings in COVID-19.Materials and MethodsIn this retrospective study, all consecutive adult hospitalized patients with PCR-positivity for SARS-CoV-2, undergoing neuroimaging at Karolinska University Hospital between March 2 and May 24, 2020, were included. All examinations were systematically re-evaluated by 12 readers. Summary descriptive statistics were calculated.Results185 patients with COVID-19 (62±14 years, 138 men) underwent neuroimaging. In total, 222 brain CT, 47 brain MRI and 7 spinal MRI scans were performed. Intra-axial susceptibility abnormalities were the most common finding (29 of 39 [74%, 95%-CI 58–87%]) in patients with brain MRI, often with an ovoid shape suggestive of microvascular pathology, and with a predilection to corpus callosum (23 of 39, [59%, 95%-CI 42–74%]) and juxtacortical areas (14 of 39, [36%, 95% CI 21-53%]). Ischemic and macrohemorrhagic manifestations were also seen, but vascular imaging did not reveal overt abnormalities. Dynamic susceptibility contrast perfusion MRI in 19 patients did not reveal consistent asymmetries between hemispheres or regions. Many patients (18 of 41 [44%, 95%-CI 28–60%]) had leukoencephalopathy and one patient had a cytotoxic lesion of the corpus callosum. Other findings included olfactory bulb signal abnormalities (7 of 37, 19%), prominent optic nerve subarachnoid spaces (20 of 36, 56%), and enhancement of the parenchyma (3 of 20, 15%), leptomeninges (3 of 20, 15%), cranial nerves (2 of 20, 10%), and spinal nerves (2 of 4, 50%). At MRI follow-up, regression of leukoencephalopathy and progressive leptomeningeal enhancement was observed in one patient respectively, suggestive of dynamic processes.ConclusionPatients with COVID-19 had a wide spectrum of vascular and inflammatory involvement of both the central and peripheral nervous system.

Cranial and extracranial giant cell arteritis share similar HLA-DRB1 association

ObjectiveTo determine whether giant cell arteritis (GCA) patients with the typical pattern of cranial ischemic manifestations and those with the extracranial large-vessel-vasculitis (LVV)-GCA phenotype exhibit different HLA-DRB1 association. Methods178 biopsy-proven GCA patients who had cranial ischemic features but no LVV manifestations, 100 patients with LVV-GCA without cranial ischemic manifestations and 486 ethnically matched healthy controls were recruited. All patients and controls were Spanish of European ancestry. We compared HLA-DRB1 phenotype frequencies between the three groups. ResultsBoth GCA subgroups had well-differentiated clinical features. Patients with LVV-GCA were younger (68.0 ± 10.0 years versus 74.0 ± 10.4 years; p < 0.01) and presented more commonly with polymyalgia rheumatica symptoms (81% versus 39.3%; p < 0.01) than those with the classic cranial GCA phenotype. HLA-DRB1*04 phenotype frequency was significantly increased in patients with classic cranial GCA compared to controls (42.1% versus 23.5%, respectively; p < 0.01; odds ratio-OR [95% confidence interval-CI] = 2.38 [1.62–3.47]). This association was mainly due to the HLA-DRB1*04:01 allele (20.8% versus 5.3%, respectively; p < 0.01; OR [95% CI] = 4.64 [2.63–8.26]). HLA-DRB1*04 association was also observed in LVV-GCA patients when compared to controls (46.0% versus 23.5%, respectively; p < 0.01; OR [95% CI] = 2.78 [1.73–4.44]). Similar to cranial GCA, the association was also mainly due to the HLA-DRB1*04:01 allele (19.0% versus 5.3%, respectively; p < 0.01; OR [95% CI] = 4.15 [2.06–8.19]). Cranial and LVV-GCA patients did not exhibit HLA-DRB1 allele differences. ConclusionCranial and extracranial LVV-GCA share similar HLA-DRB1 association.

Hemorrhagic Transformation in Ischemic Moyamoya Disease: Clinical Characteristics, Radiological Features, and Outcomes.

Objective: Hemorrhagic transformation (HT) in ischemic moyamoya disease (MMD), reasonably defined as hemorrhage events in patients with ischemic onset manifestation, leads to a poor outcome. This study aims to reveal factors associated with HT in patients with ischemic onset manifestation and to assess the outcome of these patients.Methods: A total of 683 surgically managed patients with onset ischemic manifestation were included. The clinical variables of the HT and non-HT groups were compared, and risk factors were analyzed using logistic regression analysis. Recurrent stroke events (including hemorrhagic and ischemic) during the follow-up were documented. The cumulative incidence rate of stroke events was generated via Kaplan–Meier survival analysis. Outcomes were compared between HT and non-HT groups using propensity score analysis to account for between-group differences in baseline characteristics.Results: Of 683 patients surgically treated in the overall cohort, 29 (4.3%) were classified as cases of HT. The majority manifestation of these patients was transient ischemic attack. Multivariate analysis showed that the normal cerebral perfusion according to the CT perfusion was identified as factors associated with HT [odds ratio (OR) 13.464, 95% CI 3.529–51.363, P < 0.001]. Patients who occurred HT had a worse outcome than patients without HT.Conclusions: HT in adult ischemic MMD is a rare phenomenon, but it is strongly associated with increased disability rates and mortality. The normal cerebral perfusion is a possible risk factor associated with HT in adult ischemic MMD. Recognition of HT in adult ischemic MMD may contribute to an improved outcome.

Feature of Ocular-Ischemic Syndrome in Patients with Cardiovascular Pathology. Literature Review

Vascular pathology of the vision organ is one of the leading causes of irreversible vision loss. Ocular ischemic syndrome is a serious condition that requires special attention to prevent adverse effects and outcomes. Today, this syndrome mainly occurs in the form of ischemic optic neuropathy and chronic ischemic retinopathy, which are based on damage caused by impaired perfusion in the pool of the ophthalmic artery. According to the data presented in foreign and domestic literature, there is an correlation between the ocular ischemic syndrome and the pathology of the cardiovascular system. Often, this pathology is accompanied by such diseases as: coronary heart disease, atherosclerosis, arterial hypertension, and diabetes mellitus. A number of studies have shown that an important risk factor for the development of vascular eye’s pathology is the combination of coronary heart disease with elevated total blood cholesterol and atherosclerosis in combination with arterial hypertension. Also, there are data indicating the association of the risk of ischemic opticopathy with the presence of cardiovascular diseases in patients, and vice versa, previously transferred opticopathy can be considered as predictors of cardiovascular pathology. Thus, prevention and treatment of this pathology is an interdisciplinary problem. The classical approach in the treatment of ocular ischemic syndrome today remains conservative therapy, which aims to reduce local ischemia and the effects of hypoxia. However, conservative treatment does not eliminate the main reason for the development of this condition; therefore, the search continues for new, more effective methods of preventing and treating this pathology. In recent years, data on high clinical efficacy in the treatment and prevention of ocular ischemic syndrome manifestations have appeared in the literature after surgery to restore the main blood flow at the level of the brachiocephalic arteries. A variety of cardiovascular diseases and various levels of its damage determine the approach to the treatment of this pathology. This literature review is devoted to the analysis of the causes of ocular ischemic syndrome, depending on the level of localization of the lesion of the cardiovascular system.

Poor Outcome of Intestinal Ischemic Manifestations of COVID-19

Since the end of February, Bergamo’s province in Northern Italy has become the second epicenter worldwide after Wuhan, China of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Papa Giovanni XXIII Hospital was selected as the tertiary referral center for COVID-19, with 500 dedicated beds and more than 1500 hospitalization so far. In the first 2 months’ experience, mounting evidence was collected that coagulopathy is one of the possible predictors of poor outcomes in COVID-19 patients.