Multiple Arterial Territories Research Articles

Combination of cortical-subcortical infarction with lobar microbleeds as a specific MRI pattern in patients with infective endocarditis

Background. Ischemic stroke (IS) and cerebral microbleeds (CMB) are the most common types of neurological complications of infective endocarditis (IE), while their combination is poorly understood.
 Aim. To evaluate the pattern of combination of cortical-subcortical infarction with lobar CMB or subarachnoid hemorrhage (SAH) in patients with left-sided IE.
 Materials and methods. A retrospective case-control study was conducted, including patients with IE who received cardiac surgery at the Federal Center for Cardiovascular Surgery. Inclusion criteria: age of patients 18 years; definite or possible (Duke criteria) IE of the left heart (aortic and/or mitral valves). The control group included patients without IE, with non-lacunar (likely embolic) IS. In both groups, the pattern of combination of cortical-subcortical infarction with lobar CMB or SAH was assessed. Differences between groups of patients were assessed using the 2 test, Fisher's exact test and the MannWhitney test. Additionally, odds ratios for binary features were calculated. To assess the information content of the studied pattern, classical classification quality metrics were calculated: accuracy, sensitivity, and specificity.
 Results. In patients with IS, infarcts corresponded to the main characteristics of cardioembolism: involvement of multiple cerebral arterial territories (84%), multiple infarcts (88%), cortical-subcortical localization (100%), and a high incidence of hemorrhagic transformation (44%). CMB was detected in 64% of cases (in 93.8%, CMB localization was lobar), SAH in 28% of patients (with CMB in 6 out of 7 cases). The pattern of combination of cortical-subcortical infarction with lobar CMB or SAH was observed in 64% in the IE group (in the control group in 12%). Odds ratio for the presence of IE was 13.0 (95% confidence interval 3.0455.9; p0.001). The accuracy of the sign was 76%, specificity 71%, sensitivity 84%.
 Conclusion. The combination of cortical-subcortical infarcts with lobar CMB or SAH may be a sign characteristic of IE-associated stroke.

Prognostic significance of polyvascular disease in patients admitted with acute decompensated heart failure: the ARIC Study Community Surveillance

Abstract Introduction The prevalence and outcomes of polyvascular disease (PVD) in patients admitted with acute decompensated heart failure (ADHF) have not been previously reported, nor is it known whether associations differ for heart failure (HF) with reduced vs. preserved ejection fraction (HFrEF vs HFpEF, respectively). Purpose To investigate the relationship between atherosclerotic involvement of multiple arterial territories and mortality in patients hospitalized with ADHF. Methods The Atherosclerosis Risk in Communities (ARIC) study conducted hospital surveillance of adjudicated heart failure in 4 US areas from 2005–2014, with events verified by physician review. Medical histories were abstracted from the hospital record. PVD was defined by coexisting disease in ≥2 arterial beds, identified by prevalent coronary artery disease, peripheral arterial disease, and cerebrovascular disease. Mortality hazards of PVD vs. no PVD were analyzed separately for HFpEF and HFrEF, with adjustment for age, race, sex, year of admission and geographic region. All analyses were weighted by the inverse of the sampling probability. Results Of 24,936 ADHF hospitalizations (52% female, 32% Black, mean age 75 years), 19% had PVD (22% among HFrEF hospitalizations, 17% among HFpEF hospitalizations), Figure 1. There was an increasing trend in 1-year mortality with 0, 1 and ≥2 arterial bed involvement, both for patients with HFrEF (29% to 32% to 38%; P-trend=0.0006) and HFpEF (26% to 32% to 37%; P-trend <0.0001). After adjustments, PVD was associated with a 20% higher hazard of 1-year mortality in patients with HFrEF (HR=1.23; 95% CI: 1.06–1.44) and a 30% higher hazard in patients with HFpEF (HR=1.33; 95% CI: 1.09–1.63), with no significant interaction by HF type (P-interaction = 0.5). Conclusion Patients hospitalized with ADHF and coexisting PVD have an increased risk of death, irrespective of HF type. Clinical attention should be directed toward PVD, with secondary prevention strategies enacted to improve the prognosis of this vulnerable population. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): National Institutes of Health Distributions of arterial diseaseTrends in 1-year mortality outcomes

Clinical manifestation of acute cerebral infarcts in multiple arterial territories.

ObjectivesWe aimed to assess frequencies and radiological aspects of single‐ and multiterritory clinical manifestation among patients with acute cerebral infarcts in multiple arterial territories (MACI).Materials & methodsWe retrospectively reviewed admission records and diffusion‐weighted magnetic resonance imaging of patients with MACI admitted to our stroke unit between 2006 and 2017. MACI was defined as acute cerebral ischemic lesions in at least two out of three arterial cerebral territories, that is, the left anterior, right anterior and the bilateral posterior territory. Patients with single‐ and multiterritory clinical manifestation were then compared for topographical distribution of the ischemic lesions, the number of ischemic lesions, and The Oxfordshire Community Stroke Project classification.ResultsOut of 311 patients with MACI, 222 (71.4%) presented with single‐territory clinical manifestation. Involvement of the left hemisphere (OR = 0.37, 95% CI 0.16–0.82), less than five ischemic lesions (OR = 0.58, 95% CI 0.35–0.97), and partial anterior circulation infarct clinical stroke syndrome (OR = 0.57, 95% CI 0.34–0.97) were associated with single‐territory clinical manifestation. Involvement of all three territories (OR = 2.58, 95% = 1.48–4.50), more than 10 ischemic lesions (OR = 2.30, 95% CI 1.32–4.01) and total anterior circulation infarct clinical stroke syndrome (OR = 3.31, 95% CI 1.39–7.86) were associated with multiterritory clinical manifestation.ConclusionMost patients with MACI present with single‐territory clinical manifestation on admission. Diffusion‐weighted magnetic resonance imaging is therefore necessary for a definite diagnosis.

The Proinflammatory Soluble CD40 Ligand Is Associated with the Systemic Extent of Stable Atherosclerosis.

Background and objectives: Polyvascular atherosclerosis is frequent and associated with a high cardiovascular risk, although the mechanisms regulating the atherosclerosis extent to single or multiple arterial territories are still poorly understood. Inflammation regulates atherogenesis and soluble CD40 ligand (sCD40L) is an inflammatory mediator associated with the presence of single-territorial atherosclerosis. We assessed whether the sCD40L expression is associated with the atherosclerosis extent to single or multiple arterial territories and with the atherosclerosis severity in different territories. Materials and Methods: We prospectively enrolled 94 participants with no atherosclerosis (controls, n = 26); isolated coronary atherosclerosis (group 1, n = 20); coronary and lower extremity (LE) atherosclerosis (group 2, n = 18); coronary and carotid atherosclerosis (group 3, n = 12); and coronary, LE, and carotid atherosclerosis (group 4, n = 18). Serum sCD40L levels were quantified. Results: The sCD40L levels (ng/mL, mean (standard deviation)) were 4.0 (1.5), 5.6 (2.6), 7.2 (4.2), 5.9 (3.7), and 5.1 (2.4) in controls and groups 1 to 4, respectively (ANOVA p = 0.012). In nonrevascularized patients, the sCD40L levels were significantly higher in group 2 than in group 1 and were correlated with the number of LE diseased segments. Prior LE bypass surgery was associated with lower sCD40L levels. Coexistence of coronary and LE atherosclerosis was independently associated with the sCD40L levels. Conclusions: The sCD40L levels were increased in stable atherosclerosis, particularly in polyvascular coronary and LE atherosclerosis. The number of LE diseased segments and prior LE revascularization were associated with sCD40L expression. To our knowledge, these are novel data, which provide insights into the mechanisms underlying multi-territorial atherosclerosis expression. sCD40L may be a promising noninvasive tool for refining the stratification of the systemic atherosclerotic burden.

Letter: Thrombotic Neurovascular Disease in COVID-19 Patients.

Letter: Thrombotic Neurovascular Disease in COVID-19 Patients.

Three-Vessel Anastomosis for Direct Bihemispheric Cerebral Revascularization.

In rare, complex cerebrovascular pathologies, patients may benefit from simultaneous revascularization of multiple arterial territories. Traditional strategies for these situations include the use of more than 1 interposition graft, multiple microvascular anastomoses, vessel reimplantations, and staged procedures. To improve upon traditional revascularization strategies by describing a novel 3-vessel microvascular anastomosis. This technique combines a side-to-side and an end-to-side anastomoses to facilitate simultaneous direct revascularization of 2 arterial territories in a single procedure, with a single donor vessel. We present an illustrative case of moyamoya angiopathy in which a 3-vessel anastomosis was performed in the interhemispheric fissure to simultaneously directly revascularize bilateral anterior cerebral artery (ACA) territories. A detailed step-by-step depiction of the anastomosis technique is provided. In the presented case, 3-vessel anastomosis was combined with a radial artery fascial flow-through free flap, allowing for an additional indirect revascularization. Technical execution of the 3-vessel anastomosis was uncomplicated. The patency of the anastomosis providing direct bilateral ACA territory revascularization was demonstrated intra- and postoperatively. With this report, we demonstrate technical feasibility of a novel 3-vessel anastomosis for direct 2 arterial territory revascularization This single-stage approach combines side-to-side and end-to-side techniques and has benefits over traditional revascularization techniques, as it is not deconstructive, requires only a single craniotomy and a single interposition graft, and does not require lengthy recipient artery dissection.

Trousseau Syndrome Related Cerebral Infarction: Clinical Manifestations, Laboratory Findings and Radiological Features

We summarized the clinical manifestations, laboratory data, and brain MRI of patients with Trousseau syndrome related cerebral infarction and compared them to patients with other types of cerebral infarction. Through our present research, we hope to aid the neurologists in recognizing and diagnosing this syndrome. A total of 31 patients at our institution were identified with cerebral infarction resulting from Trousseau syndrome. We have also selected the 180 patients who have suffered from cerebral infarction as control groups and these patients were distributed to large-artery atherosclerosis group; cardio-embolism group; small-artery occlusion group, according to Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. The clinical data and neuroimage of these patients were collected. All our 31 cancer patients were confirmed by pathological biopsy to be adenocarcinomas and the most common cancers are gastric and lung cancers. Patients with Trousseau syndrome exhibited high serum carbohydrate antigen CEA, CA 125 and CA 199 levels. Compared to patients with other types of cerebral infarction, patients with Trousseau syndrome had an increased severity and worse prognosis. Besides, patients had the highest mean level of plasma D-dimer. We also found multiple lesions in multiple vascular territories was the most frequent type of DWI patterns in patients of Trousseau syndrome. Trousseau syndrome can progress rapidly and become life-threatening. For patients who developed unexplained cerebral infarction involving multiple arterial territories, with elevated plasma D-dimer and cancer antigens, Trousseau syndrome should always be considered.

Ability of the number of territories involved on DWI-MRI to predict occult systemic malignancy in cryptogenic stroke patients

BackgroundLesions in multiple arterial territories is one of the typical features of malignancy patients with cryptogenic stroke. Hence, if patients with cryptogenic stroke display such feature, occult cancer could be predicted. The study aimed to analyze the predictive ability of the number of territories involved on DWI-MRI for occult systemic malignancy (OSM) in patients with cryptogenic stroke. MethodsWe enrolled patients with cryptogenic stroke without a diagnosis of malignancy at stroke onset between January 2013 and November 2018. Clinical variables were analyzed between cryptogenic stroke patients with and without OSM through univariate and multiple logistic regression analyses. Points for OSM were generated by β-coefficients. The sensitivity and specificity of the risk score were assessed by the area under the receiver operating characteristic curve (AUROC). The cutoff value for predicting OSM was determined by the maximum Youden index. ResultsAmong 108 cyptogenic stroke patients, compared to patients without OSM (n = 96), patients with OSM (n = 12) had a lower nutrition status (P = 0.031), higher plasma D-dimer levels (P < 0.001) and more territories involved on DWI-MRI (P < 0.001). Multiple logistic regression analysis revealed that plasma D-dimer levels (OR, 3.54; 95% Cl, 1.62–7.76; P = 0.002) and the number of territories involved (OR, 4.45; 95% CI, 1.25–15.80; P = 0.021) independently predicted OSM. The predictive score system built upon the number of territories showed good discrimination with an AUROC of 0.84 (95% CI, 0.71–0.96). The cutoff value was 2 with a maximum Youden's index of 0.56, which means that patients with more than one territory involved on DWI-MRI may need extensive screening for OSM. ConclusionsThe number of territories involved on DWI-MRI was a valid predictor for OSM in cryptogenic stroke patients who need to undergo further evaluations .

Short-Term Outcome and In-Hospital Complications After Acute Cerebral Infarcts in Multiple Arterial Territories.

Background and Purpose- Patients with acute cerebral infarcts in multiple arterial territories (MACI) represent a substantial portion of the stroke population. There are no data on short-term outcome and in-hospital complications in patients with MACI. We compared patients with MACI with patients having acute cerebral infarct(s) in a single arterial territory. Methods- We analyzed 3343 patients with diffusion-weighted imaging-confirmed acute cerebral infarcts. MACI was defined as at least 2 acute cerebral ischemic lesions in at least 2 arterial cerebral territories. Patients with MACI were compared with patients with acute cerebral infarct(s) in a single arterial territory for relevant in-hospital complications and short-term outcome, namely National Institutes of Health Stroke Scale and modified Rankin Scale at day 7 after admission or at discharge when earlier. Results- A total of 311 patients (9.3%) met the definition of MACI. Both median National Institutes of Health Stroke Scale (2 [1-7] versus 1 [0-4]) and modified Rankin Scale (3 [1-4] versus 2 [1-3]) were higher in patients with MACI. MACI was independently associated with higher National Institutes of Health Stroke Scale and modified Rankin Scale. Deep venous thrombosis, myocardial infarction, and any complications were more frequent in patients with MACI. Conclusions- In-hospital complications were more frequent in patients with MACI, which may adversely affect short-term clinical and functional outcome. Closer follow-up of patients with MACI during hospitalization may prevent such events and negative progression.

Etiologies of simultaneous cerebral infarcts in multiple arterial territories: A simple literature-based pooled analysis.

Acute multiple infarcts in multiple cerebral circulations are thought to suggest the presence of cardioembolic sources. However, several studies have shown other etiologies for simultaneous cerebral infarcts in multiple arterial territories. We conducted a systematic review of the literature using PubMed, Scopus, Embase, Clinicaltrial.gov, WHO International Clinical Trials Registry Platform (ICTRP), and Cochrane library. Studies reporting multiple acute strokes in more than one arterial territory based on diffusion-weighted imaging (DWI) findings were reviewed and included. Studies were excluded if they had limited inclusion criteria, performed limited subgroup analysis, did not use diffusion weighted imaging (DWI), and were not published in English. Out of 15056 stroke patients from 21 studies included in this study, 1914 (13%) patients had acute multiple infarcts in multiple cerebral circulations. One hundred and ninety-nine patients were excluded as their workup and diagnosis were not reported. Out of 1715 patients, 472 (27.6%) patients had an undetermined etiology. Cardioembolism was the most common cause of stroke in multiple arterial territories [37.2%, 95% confidence interval (CI): 36-40%] followed by large artery atherosclerosis including aortic arch atheroma (25.7%, 95% CI: 21-25%). Hematological disorders were found to be the cause of cerebral infarcts in 36 (2.1%, 95% CI: 2-4%) patients. Other etiologies for stroke in multiple arterial territories were small vessel pathologies and intracranial small vessel atherosclerosis (1.8%), inflammatory disorders such as vasculitis and infection (0.2%), and iatrogenic causes (0.1%). Acute multiple infarcts in multiple cerebral circulations occur among 13% of stroke patients. Although cardioembolism is the most common cause, there are several other etiologies that require a different workup and secondary prevention strategy.

Factors Associated With Remote Diffusion-Weighted Imaging Lesions in Spontaneous Intracerebral Hemorrhage.

Remote diffusion-weighted imaging lesions (R-DWILs) have been detected in patients with spontaneous intracerebral hemorrhage (ICH) and may be correlated with clinical outcome. However, the mechanisms and characteristics of R-DWILs have not been fully elucidated. In this study, we sought to demonstrate the clinical characteristics of R-DWILs in spontaneous ICH. We prospectively collected data with spontaneous ICH patients from November 2016 to December 2017. In these patients, cerebral magnetic resonance imaging was performed within 28 days after ICH onset. R-DWIL was defined as a hyperintensity signal in diffusion-weighted imaging with corresponding hypointensity in apparent diffusion coefficient, and at least 20 mm apart from the hematoma. We compared two groups of patients with or without R-DWIL with the demographic and clinical characteristics, laboratory parameters, and imaging characteristics, by using univariate and multivariate analysis. Of the 222 patients enrolled, a total of 75 R-DWILs were observed in 41 patients (18.5%). Among these lesions, the cortical and subcortical areas were the predominant locations with a proportion of 77.3%. The median diameter of R-DWILs was 7 mm (range 2-20 mm). Twelve patients were found having more than one lesion, with five among which showed R-DWILs in multiple cerebral arterial territories. In multivariate modeling, higher fasting glucose (OR 1.231; 95% CI 1.035-1.465; p = 0.019) and more severe white matter hyperintensity (WMH) (OR 6.589; 95% CI 2.975-14.592; p < 0.001) were independent factors related to the presence of R-DWILs. In our study, approximately one-fifth of ICH patients showed coexistence of R-DWIL. Higher fasting glucose and more severe WMH were associated with R-DWIL occurrence in spontaneous ICH.

Severe Fatal Systemic Embolism Due to Non-Bacterial Thrombotic Endocarditis as the Initial Manifestation of Gastric Adenocarcinoma: Case Report.

IntroductionNonbacterial thrombotic endocarditis (NBTE), also known as marantic endocarditis, is a rare, underdiagnosed complication of cancer, in the context of a hypercoagulable state. NBTE represents a serious complication due to the high risk of embolisation from the sterile cardiac vegetations. If these are not properly diagnosed and treated, infarctions in multiple arterial territories may occur.Case presentationThe case of a 47-year-old male is described. The patient was diagnosed with a gastric adenocarcinoma, in which the first clinical manifestation was NBTE. Subsequently, a hypercoagulability syndrome was associated with multi-organ infarctions, including stroke and eventually resulted in a fatal outcome.ConclusionsNBTE must be considered in patients with multiple arterial infarcts with no cardiovascular risk factors, in the absence of an infectious syndrome and negative blood cultures. Cancer screening must be performed to detect the cause of the prothrombotic state.

Carotid IM-GSM is better than IMT for identifying patients with multiple arterial disease

Objective. Atherosclerosis is a systemic inflammatory disease that can affect more than one arterial bed simultaneously. The aim of this study was to determine the relationship between ultrasound markers of atherosclerosis and multiple arterial disease. Design. We have included 87 currently asymptomatic carotid disease patients (mean age 69 ± 6 year, 34% females) in this study. Intima media thickness (IMT) and intima media-grey scale median (IM-GSM) were measured in the common carotid artery (CCA), and correlated with previous and/or current atherosclerotic vascular disease in the coronary, carotid and lower extremities. Patients were divided into three groups: (1) asymptomatic, (2) previous symptoms in one arterial territory and (3) previous symptoms in multiple arterial territories. Results. Patients with previous disease in the coronary arteries had higher IMT (p = .034) and lower IM-GSM (p < .001), and those with prior stroke had lower IM-GSM (p = .007). Neither IMT nor IM-GSM was different between patients with and without previous lower extremity vascular disease. IM-GSM was significantly different between groups, it decreased significantly with increasing number of arterial territories affected (37.7 ± 15.4 vs. 29.3 ± 16.4 vs. 20.7 ± 12.9) p < .001, for asymptomatic, symptoms in one and in multiple arterial systems, respectively. Conventional IMT was not significantly different between groups p = .49. Conclusion. Carotid IMT was higher and IM-GSM lower in patients with symptomatic nearby arterial territories but not in those with peripheral disease. In contrast to conventional IMT, IM-GSM can differentiate between numbers of arterial territories affected by atherosclerosis, suggesting that it is a better surrogate for monitoring multiple arterial territory disease.

Abstract WP211: Mechanism of Simultaneous Cerebral Infarcts in Multiple Arterial Territories: A Literature-Based Pooled Analysis

Introduction: Acute multiple cerebral infarcts in multiple arterial territories are thought to suggest the presence of cardioembolic sources. However, several studies have shown other etiologies for simultaneous cerebral infarcts in multiple arterial territories. Methods: We conducted a systematic review of the literature through PubMed, Scopus, Embase, Clinicaltrial.gov, ICTRP and Cochrane library. Studies containing multiple acute strokes in more than one arterial territory based on diffusion weighted imaging (DWI) findings were screened. Articles were excluded if they had limited inclusion criteria, performed limited subgroup analysis, or did not use DWI. Results: Out of 16551 stroke patients from 25 studies included in this study, 1967 (12%) patients had simultaneous acute cerebral infarcts in multiple arterial territories. 199 patients were excluded as their workup and diagnosis were not reported. Out of 1768 patients, 491 (28%) patients had an undetermined etiology. Cardioembolism was the most common cause of stroke in multiple arterial territories (38%, 95%CI: 36-40%) followed by large artery atherosclerosis including aortic arch atheroma (23%, 95%CI: 21-25%). Hematological disorders were found to be the cause of cerebral infarcts in 52 (3%, 95%CI: 2-4%) patients. Out of 143 patients who were reported to have simultaneous brain infarcts in bilateral hemispheres or anterior and posterior circulations, 78 (54%, 95%CI: 46-62%) were found to have cardiacembolism. Other etiologies for stroke in multiple arterial territories were intracranial atherosclerosis, vasculitis and other inflammatory diseases, infection, and iatrogenic causes. Conclusion: Simultaneous cerebral infarcts in multiple arterial territories occur among 12% of stroke patients. Although cardioembolism is the most common cause, there are several other etiologies that require a different workup and secondary prevention strategy.

Acute cerebral infarcts in multiple arterial territories associated with cardioembolism.

It is generally believed that cardioembolism is the main cause of multiple acute cerebral infarcts (MACI). However, there are surprisingly few DWI studies and results are conflicting. Based on a large prospective study we hypothesized that MACI are associated with cardioembolism. We studied 2697 patients with acute cerebral infarcts between February 2006 and October 2013 who were prospectively registered in The Bergen NORSTROKE Registry. Among them, 2220 (82.3%) patients underwent magnetic resonance imaging (MRI) and 2125 (96%) of these 2220 patients had DWI lesions. Only patients with DWI lesions were included. MACI were defined as at least two DWI lesions in at least two different arterial territories. MACI were detected in 187/2125 (8.8%) patients with DWI lesions. MACI patients were older and more often females. MACI were associated with cardioembolism (P = 0.042), especially atrial fibrillation (P = 0.002). Other associations were symptomatic internal carotid artery (ICA) stenosis (P = 0.014), asymptomatic ICA stenosis (P = 0.036), and higher NIHSS score on admission (P < 0.001). Among patients with no cardioembolism, 34 (35%) with MACI had symptomatic ICA stenosis versus 268 (25.0%) with non-MACI (P = 0.037); 20 (20%) with MACI had asymptomatic ICA stenosis versus 134 (13%) with non-MACI (P = 0.031). In the logistic regression analysis, cardiac embolism and symptomatic ICA stenosis were independently associated with MACI. Acute cerebral infarcts in more than one arterial territory occur among almost 10% of the patients and are associated with cardioembolism.

Co-existence of vascular disease in different arterial beds: Peripheral artery disease and carotid artery stenosis--Data from Life Line Screening(®).

Atherosclerosis is a systemic vascular disorder, involving multiple arterial territories. This project sought to investigate the relationship between lower extremity peripheral artery disease (PAD) and carotid artery stenosis (CAS) in a large self-referred population. Data from the ankle brachial index (ABI) and carotid duplex ultrasound were analyzed from 3.67 million US subjects in the Life Line Screening program between 2004 and 2008. PAD was defined by ABI<0.9 and CAS was defined by greater than 50% stenosis. Multivariate logistic regression analysis was used to estimate odds of CAS by PAD status and severity. Mean age of the population was 63.7±10.6 years and 64% were women. The prevalence of PAD and CAS was 4.1% and 3.9%, respectively. Subjects with PAD had a higher prevalence of CAS than those without PAD (18.8% vs. 3.3%, P<0.0001). In multivariate analysis, PAD was associated with greater odds of CAS (OR 3.28, 95% CI 3.22-3.34). Both symptomatic (OR 3.66, 95% CI 3.58-3.75) and asymptomatic PAD (OR 2.91, 95% CI 2.84-2.98) was associated with CAS. Increasing severity of PAD was associated with greater odds of CAS (OR 2.32, 3.61, 4.19, 5.14, and 7.59 for ABI categories 0.81-0.90, 0.71-0.80, 0.61-0.70, 0.41-0.60, ≤0.40, respectively). Presence and severity of PAD was associated with prevalence of CAS in the large self-referred and self-paying Life Line cohort, regardless of lower extremity symptoms.

Scorpion Stings: Focus on Cerebrovascular Complications of Envenoming

Dear editor, Scorpion stings kills thousands of people every year (1). Clinical picture of envenoming is dominated by local pain, weakness, arterial hypertension, cardiac arrhythmias, myocarditis, or pulmonary oedema. These manifestations occur as the result of massive release of catecholamines into the bloodstream or due to direct toxicity of the venom (2). Cerebrovascular complications occur in up to 8% of severely envenomed scorpion sting victims, particularly after the sting of Mesobuthus thalamus (Indian red scorpion). Intracranial haemorrhages occur in the setting of acute increases in blood pressure related to sympathetic overstimulation, and cerebral infarctions are related to cerebral hypoperfusion, consumption coagulopathy, vasculitis, intracranial vessels spasm, or cardiogenic brain embolism (3,4). A PubMed search revealed 23 well-documented cases of stroke following scorpion stings (mean age 25 years; 71% men). Fifteen patients (65%) had ischaemic and eight had haemorrhagic strokes. Infarctions were located in the middle cerebral artery territory (six patients), watershed areas between major cerebral arteries (three patients), the cerebellum (two patients), multiple arterial territories (two patients), and the posterior cerebral artery territory and the pons (one patient each). Pathogenetic mechanisms responsible for the infarction were suspected in 13 patients, six of whom had cerebral hypoperfusion (related to systemic hypotension), four had disseminated intravascular coagulation, two had vasculitis, and one had spasm of intracranial arteries. Haemorrhagic strokes were located in the basal ganglia in four cases, the subcortical white matter in two, and the ventricular system in one. The remaining patient had multiple intracranial haemorrhages. In seven cases, the cause of the haemorrhage was an increase in arterial blood pressure occurring as part of the ‘autonomic storm’ observed in scorpion sting victims. Prompt management of these patients reduces stroke morbidity and mortality. Prazosin reverses the overstimulation of peripheral a1-adrenergic receptors and reduces the risk of cardiac and pulmonary complications. While the use of antivenom has been questioned due to allergic reactions, combination therapy with antivenom plus prazosin was more effective than prazosin alone for enhancing recovery in a recent trial (5).

Ischemic Stroke in Cancer Patients With and Without Conventional Mechanisms

To assess the precise mechanisms of stroke in cancer patients, we analyzed the data for cancer patients with acute ischemic stroke registered from 6 centers in South Korea. Clinical features, risk factors, diffusion-weighted imaging lesion patterns, and laboratory findings including D-dimer levels were compared between patients with conventional stroke mechanisms (CSMs) and cryptogenic group. A total of 161 patients were included in this study: 97 (60.2%) patients in the CSM group and 64 (39.8%) in the cryptogenic group. Patients in the CSM group were older and vascular risk factors were more prevalent than in the cryptogenic group. Diffusion-weighted imaging patterns of multiple lesions involving multiple arterial territories were observed more frequently in the cryptogenic group than in the CSM group. In addition, levels of the D-dimer were higher in the cryptogenic group than in the CSM group (11.5+/-14.6 versus 3.6+/-10.3 microg/dL). In multivariate analysis, the diffusion-weighted imaging lesion pattern of multiple vascular territories (odds ratio, 11.2; 95% CI, 3.74 to 33.3), and D-dimer levels of >1.11 microg/dL (odds ratio, 10.6; 95% CI, 3.29 to 33.8) were associated independently with the cryptogenic group. Stroke outside of CSM occurred in a large number in cancer patients. In stroke patients with cancer, d-dimer levels and diffusion-weighted imaging lesion patterns may be helpful in early identification of non-CSMs (especially coagulopathy associated with cancer) and possibly in guiding preventive strategies for stroke.

Safety and tolerability of Ramipril 10 mg in high risk Bangladeshi patients following the criteria of the HOPE study: A multi center open, non comparative study

Renin angiotensin aldosterone system plays an important role in the pathogenesis of cardiovascular events. ACE inhibitors are known to have a beneficial effect on atherosclerosis progression affecting multiple arterial territories of the body. Several outcome trials utilizing ACE inhibitors have shown reduction of death, NH and stroke in broad range of patients. HOPE study, the landmark trial using Ramipril, has shown beneficial effects in high risk patients using Ramipril 10mg/day in the western population. The aim of the present study was to evaluate the safety and tolerability of Ramipril 10mg/day in Bangladeshi patients. The criteria for recruitment were similar to those of the HOPE study except age (45 years or older were included in the present study). The study showed that this target dose of Ramipril would be reached in Bangladeshi patients, as in the HOPE study, in order to achieve a full therapeutic effect. Lower incidence of adverse events and less distontinuation rate of the drug was encouraging. It is concluded from the study results that Ramipril at a dose of 10mg/day can be used in Bangladeshi patients with reasonable safety and are well tolerated. doi: 10.3329/uhj.v5i1.3432 University Heart Journal Vol. 5, No. 1, January 2009 3-8

Prior polyvascular disease: risk factor for adverse ischaemic outcomes in acute coronary syndromes

The presence of peripheral arterial disease (PAD) or cerebrovascular disease (CVD) is associated with higher likelihood of significant coronary artery disease (CAD). We sought to assess the prevalence of PAD, CVD, prior CAD, or pre-existent disease in multiple arterial territories ('polyvascular' disease) in patients presenting with non-ST-segment elevation acute coronary syndrome and its impact on adverse events. Data from 95 749 patients enrolled from February 2003 to September 2006 at 484 sites in the CRUSADE registry were analysed. Patients were categorized as having prior 0, 1, 2, or 3 affected arterial beds. The rates of in-hospital mortality, myocardial infarction, stroke, and congestive heart failure were analysed, as were the rates of non-bypass surgery-related red blood cell transfusion and major bleeding. On presentation, 11,345 (11.9%) patients had established PAD, 9973 (10.4%) had documented CVD, and 41,404 (43.2%) had prior CAD. In this cohort, 0, 1, 2, and 3 arterial bed disease before presentation was present in 46 814 (48.9%, 95% CI 48.6-49.2%), 36 704 (38.3%, 95% CI 37.8-39.0%), 10 675 (11.2%, 95% CI 10.9-11.9%), and 1556 (1.6%, 95% CI 1.5-1.8%) patients, respectively. The rates of ischaemic events increased with the number of affected vascular beds. The adjusted odds ratio for the composite of in-hospital ischaemic events for pre-existent disease in 1, 2, or 3 arterial beds (compared with 0 arterial bed involvement) increased from 1.07 to 1.26 to 1.31 (P < 0.001). Similarly, the adjusted odds ratio for transfusion increased with greater disease burden from 1.11 to 1.28 to 1.30 (P < 0.001), although the adjusted rates of protocol-defined non-bypass surgery-related major bleeding did not. Prior polyvascular disease increases the risk of in-hospital adverse events, including mortality. Identification of these patients in clinical trial and real world populations may provide an opportunity to reduce their excess risk with intensive secondary prevention efforts.