Perfusion Deficits Research Articles

Laparoscopic Laser Speckle Contrast Imaging Can Visualize Anastomotic Perfusion: A Demonstration in a Porcine Model.

Background: Intestinal resection causes inevitable vascular damage, which cannot always be seen during an intraoperative clinical assessment of local intestinal perfusion. If left unaltered, impaired perfusion can lead to complications, such as anastomotic leakage (AL). Therefore, we demonstrate the use of a novel laparoscopic laser speckle contrast imaging (LSCI)-based approach in order to assess local intestinal perfusion during the construction of intestinal anastomoses. Methods: Three segments were isolated from the small intestine of a pig, while the perfusion of each was compromised by coagulating 7–8 mesenteric arteries. Both clinical assessments and LSCI were used to detect the induced perfusion deficits and to subsequently guide a transection in either a well perfused, marginally perfused, or poorly perfused tissue area within the segment. Bowel ends were then utilized for the creation of three differently perfused anastomoses: well perfused/well perfused (anastomosis segment 1), well perfused/poorly perfused (anastomosis segment 2), and poorly perfused/poorly perfused (anastomosis segment 3). After construction of the anastomoses, a final perfusion assessment using both clinical assessment and LSCI was executed in order to evaluate the vascular viability of the anastomosis. Results: Laparoscopic LSCI enabled continuous assessment of local intestinal perfusion and allowed for detection of perfusion deficits in real time. The imaging feedback precisely guided the surgical procedure, and, when evaluating the final anastomotic perfusion, LSCI was able to visualize the varying degrees of perfusion, whereas standard clinical assessment yielded only minor differences in visual appearance of the tissue. Conclusions: In this technical note, we demonstrate a novel LSCI-based approach for intraoperative perfusion assessment. With its ability to continuously visualize perfusion in real time, laparoscopic LSCI has significant potential for the optimization of anastomotic surgery in the near future.

Blood Flow Changes Associated with Spinal Cord Injury Assessed by Non-linear Doppler Contrast-Enhanced Ultrasound.

Contrast-enhanced ultrasound (CEUS) is clinically used to image the microcirculation at lower imaging frequencies (<2 MHz). Recently, plane-wave acquisitions and Doppler processing have revealed improved microbubble sensitivity, enabling CEUS use at higher frequencies (15 MHz) and the ability to image simultaneously blood flow in the micro- and macrocirculations. We used this approach to assess acute and chronic blood flow changes within contused spinal cord in a rodent spinal cord injury model. Immediately after spinal cord injury, we found significant differences in perfusion deficit between moderate and severe injuries (1.73 ± 0.1 mm2 vs. 3.2 ± 0.3 mm2, respectively), as well as a delay in microbubble arrival time in tissue adjacent to the injury site (0.97 ± 0.1 s vs. 1.54 ± 0.1 s, respectively). Acutely, morphological changes to central sulcal arteries were observed where vessels rostral to the contusion were displaced 4.8 ± 2.2° and 8.2 ± 3.1° anteriorly, and vessels caudal to the contusion 17.8 ± 3.9° and 24.2 ± 4.1° posteriorly, respectively, for moderate and severe injuries. Significant correlation of the acute perfusion deficit and arrival time were found with the chronic assessment of locomotive function and histological estimate of spared spinal cord tissue.

Prediction of 2-year major adverse cardiac events from myocardial perfusion scintigraphy and clinical risk factors

BackgroundWe developed CRAX2MACE, a new tool derived from clinical and SPECT myocardial perfusion imaging (MPI) variables, to predict 2-year probability of major adverse cardiac event (MACE) comprising death, hospitalized acute myocardial infarction or coronary revascularization. MethodsConsecutive individuals with SPECT MPI 2001-2008 had two-year MACE determined from population-based health services data. CRAX2MACE included age, sex, diabetes, recent cardiac hospitalization, pharmacologic stress, stress total perfusion deficit (TPD), ischemic (stress-rest) TPD, left ventricular ejection fraction and transient ischemic dilation ratio. Two-year event rates were classified as low (< 5%), moderate (5.0-9.9%), high (10-19.9%) and very high (20% or greater). ResultsThe study population comprised 3896 individuals for the development and 1946 for the validation subgroups with subsequent MACE in 589 (15.1%) and 272 (14.0%), respectively. CRAX2MACE, derived from the development subgroups, accurately stratified MACE risk in the validation subgroup (area under the receiver operating characteristics curve 0.79) with stepwise increase in the observed event rate with increasing predicted risk category (low, 2.3%; moderate, 5.5%; high, 18.8%; very high 33.2%; P-trend < 0.001). ConclusionsA simple tool based upon clinical risk factors and MPI variables predicts 2-year cardiac events. Risk stratification between the low and very high groups was greater than tenfold.

Estimating Perfusion Deficits in Acute Stroke Patients Without Perfusion Imaging.

Perfusion weighted imaging (PWI) is critical for determining whether stroke patients presenting in an extended time window are candidates for mechanical thrombectomy. However, PWI is not always available. Fluid-attenuated inversion recovery hyperintense vessels (FHVs) are seen in patients with a PWI lesion. We investigated whether a scale measuring the extent FHV could serve as a surrogate for PWI to determine eligibility for thrombectomy. The National Institutes of Health (NIH) FHV score was developed to quantify the burden of FHV and applied to magnetic resonance imaging scans of stroke patients with fluid-attenuated inversion recovery and perfusion imaging. The NIH-FHV was combined with the diffusion weighted image volume to estimate the diffusion-perfusion mismatch ratio. Linear regression was used to compare PWI volumes and mismatch ratios with estimates from the NIH-FHV score. Receiver operating characteristic analysis was used to test the ability of the NIH-FHV score to identify a significant mismatch. There were 101 patients included in the analysis, of whom 78% had a perfusion deficit detected on PWI with a mean lesion volume of 47 (±59) mL. The NIH-FHV score was strongly associated with the PWI lesion volume (P<0.001; R2=0.32; β-coefficient, 0.57). When combined with diffusion weighted image lesion volume, receiver operating characteristic analysis testing the ability to detect a mismatch ratio ≥1.8 using the NIH-FHV score resulted in an area under the curve of 0.94. The NIH-FHV score provides an estimate of the PWI lesion volume and, when combined with diffusion weighted imaging, may be helpful when trying to determine whether there is a clinically relevant diffusion-perfusion mismatch in situations where perfusion imaging is not available. Further studies are needed to validate this approach.

Case Report – Successful Thrombectomy After Critical Resuscitation Following a Cardiac Arrest

Sparse evidence exists to support a delayed attempt at thrombectomy after a periprocedural cardiac arrest or acute medical decompensation. This case highlights the presentation of a 23‐year‐old woman with dilated cardiomyopathy, who initially presented with a left middle cerebral artery stroke syndrome, but who had a cardiac arrest in the angiogram suite prior to the procedure starting. After aggressive resuscitation in the critical care unit, repeat imaging showed a persistent perfusion deficit in the left middle cerebral artery territory and she successfully underwent a thrombectomy. The case highlights that critical care efforts, even after a severe initial presentation, and significant resuscitative efforts in the intensive care unit setting, can still lead to a successful thrombectomy, and that eligibility for thrombectomy can be reassessed as the patient stabilizes.

Association of Intravenous Thrombolysis with Delayed Reperfusion After Incomplete Mechanical Thrombectomy

PurposeTreatment of distal vessel occlusions causing incomplete reperfusion after mechanical thrombectomy (MT) is debated. We hypothesized that pretreatment with intravenous thrombolysis (IVT) may facilitate delayed reperfusion (DR) of residual vessel occlusions causing incomplete reperfusion after MT.MethodsRetrospective analysis of patients with incomplete reperfusion after MT, defined as extended thrombolysis in cerebral infarction (eTICI) 2a–2c, and available perfusion follow-up imaging at 24 ± 12 h after MT. DR was defined as absence of any perfusion deficit on time-sensitive perfusion maps, indicating the absence of any residual occlusion. The association of IVT with the occurrence of DR was evaluated using a logistic regression analysis adjusted for confounders. Sensitivity analyses based on IVT timing (time between IVT start and the occurrence incomplete reperfusion following MT) were performed.ResultsIn 368 included patients (median age 73.7 years, 51.1% female), DR occurred in 225 (61.1%). Atrial fibrillation, higher eTICI grade, better collateral status and longer intervention-to-follow-up time were all associated with DR. IVT did not show an association with the occurrence of DR (aOR 0.80, 95% CI 0.44–1.46, even in time-sensitive strata, aOR 2.28 [95% CI 0.65–9.23] and aOR 1.53 [95% CI 0.52–4.73] for IVT to incomplete reperfusion following MT timing <80 and <100 min, respectively).ConclusionA DR occurred in 60% of patients with incomplete MT at ~24 h and did not seem to occur more often in patients receiving pretreatment IVT. Further research on potential associations of IVT and DR after MT is required.

Differences in Automated Perfusion Software: Do They Matter Clinically?

Differences in Automated Perfusion Software: Do They Matter Clinically?

Deep Capillary Nonperfusion on OCT Angiography Predicts Complications in Eyes with Referable Nonproliferative Diabetic Retinopathy

To evaluate the ability of capillary nonperfusion parameters on OCT angiography (OCTA) to predict the development of clinically significant outcomes in eyes with referable nonproliferative diabetic retinopathy (NPDR). Prospective longitudinal observational study. In total, 59 patients (74 eyes) with treatment-naive moderate and severe (referable) NPDR. Patients were imaged with OCTA at baseline and then followed-up for 1 year. We evaluated 2 OCTA capillary nonperfusion metrics, vessel density (VD) and geometric perfusion deficits (GPDs), in the superficialcapillary plexus, middle capillary plexus (MCP), and deep capillary plexus (DCP). We compared thepredictive accuracy of baseline OCTA metrics for clinically significant diabetic retinopathy (DR) outcomes at1year. Significant clinical outcomes at 1 year, defined as 1 or more of the following-vitreous hemorrhage, center-involving diabetic macular edema, and initiation of treatment with pan-retinal photocoagulation or anti-VEGF injections. Overall, 49 patients (61 eyes) returned for the 1-year follow-up. Geometric perfusion deficits and VD in the MCP and DCP correlated with clinically significant outcomes at 1 year (P < 0.001). Eyes with these outcomes had lower VD and higher GPD, indicating worse nonperfusion of the deeper retinal layers than those that remained free from complication. These differences remained significant (P= 0.046 to < 0.001) when OCTA parameters were incorporated into models that also considered sex, baseline corrected visual acuity, and baseline DR severity. Adjusted receiver operating characteristic curve for DCP GPD achieved an area under the curve (AUC) of 0.929, with sensitivity of 89% and specificity of 98%. In a separate analysis focusing on high-risk proliferative diabetic retinopathy outcomes, MCP and DCP GPD and VD remained significantly predictive with comparable AUC and sensitivities to the pooled analysis. Evidence of deep capillary nonperfusion at baseline in eyes with clinically referable NPDR can predict short-term DR complications with high accuracy, suggesting that deep retinal ischemia has an important pathophysiologic role in DR progression. Our results suggest that OCTA may provide additional prognostic benefit to clinical DR staging in eyes with high risk.

Diabetic macular ischaemia- a new therapeutic target?

Diabetic macular ischaemia (DMI) is traditionally defined and graded based on the angiographic evidence of an enlarged and irregular foveal avascular zone. However, these anatomical changes are not surrogate markers for visual impairment. We postulate that there are vascular phenotypes of DMI based on the relative perfusion deficits of various retinal capillary plexuses and choriocapillaris. This review highlights several mechanistic pathways, including the role of hypoxia and the complex relation between neurons, glia, and microvasculature. The current animal models are reviewed, with shortcomings noted. Therefore, utilising the advancing technology of optical coherence tomography angiography (OCTA) to identify the reversible DMI phenotypes may be the key to successful therapeutic interventions for DMI. However, there is a need to standardise the nomenclature of OCTA perfusion status. Visual acuity is not an ideal endpoint for DMI clinical trials. New trial endpoints that represent disease progression need to be developed before irreversible vision loss in patients with DMI. Natural history studies are required to determine the course of each vascular and neuronal parameter to define the DMI phenotypes. These DMI phenotypes may also partly explain the development and recurrence of diabetic macular oedema. It is also currently unclear where and how DMI fits into the diabetic retinopathy severity scales, further highlighting the need to better define the progression of diabetic retinopathy and DMI based on both multimodal imaging and visual function. Finally, we discuss a complete set of proposed therapeutic pathways for DMI, including cell-based therapies that may provide restorative potential.

Association of hyperglycemia and computed tomographic perfusion deficits in patients who underwent endovascular treatment for acute ischemic stroke caused by a proximal intracranial occlusion: A subgroup analysis of a randomized phase 3 trial (MR CLEAN)

IntroductionHyperglycemia is highly prevalent in patients with acute ischemic stroke and is associated with increased risk of symptomatic intracranial hemorrhage, larger infarct size and unfavorable outcome. Furthermore, glucose may modify the effect of endovascular treatment (EVT) in patients with ischemic stroke. Hyperglycemia might lead to accelerated conversion of penumbra into infarct core. However, it remains uncertain whether hyperglycemia on admission is associated with the size of penumbra or infarct core in acute ischemic stroke. In this study, we aimed to assess the association between hyperglycemia and Computed Tomographic Perfusion (CTP) derived parameters in patients who underwent EVT for acute ischemic stroke. MethodsWe used data from the MR CLEAN study (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands). Hyperglycemia was defined as admission serum glucose of >7.8 mmol/L. Dichotomized and quantiles of glucose levels were related to size of core, penumbra and core penumbra ratio. Hypoperfused area is mean transient time 45% higher than that of the contralateral hemisphere. Core is the area with cerebral blood volume of <2 mL/100 g and penumbra is the area with cerebral blood volume > 2 mL/100 g. Core-penumbra ratio is the ischemic core divided by the total volume of hypoperfused tissue (core plus penumbra) multiplied by 100. Adjustments were made for age, sex, NIHSS on admission, onset-imaging time and diabetes mellitus. ResultsHundred seventy-three patients were included. Median glucose level on admission was 6.5 mmol/L (IQR 5.8–7.5 mmol/L) and thirty-five patients (20%) were hyperglycemic. Median core volume was 33.3 mL (IQR 13.6–62.4 mL), median penumbra volume was 80.2 mL (IQR 36.3–123.5 mL) and median core-penumbra ratio was 28.5% (IQR 18.6–45.8%). Patients with hyperglycemia on admission had larger core volumes and core penumbra ratio than normoglycemic patients with a regression coefficient of 15.1 (95% confidence interval (CI), 1.8 to 28.3) and 11.5 (95% confidence interval (CI), 3.4 to 19.7) respectively. ConclusionHyperglycemia on admission was associated with larger ischemic core volume and larger core-penumbra ratio in patients with acute ischemic stroke who underwent endovascular treatment.

Investigation of the Clinical Efficacy of 99mTc-Sestamibi Washout in Patients with Acute Myocardial Infarction and Comparison with Stress Myocardial Imaging with 99mTc-Sestamibi Using a Two-Day Protocol

Background: 99mTc-sestamibi myocardial perfusion imaging (MIBI) washout is associated with myocardial mitochondrial damage in patients with a successful percutaneous coronary intervention (PCI) following acute myocardial infarction (AMI) and may predict the functional improvement of the left ventricle in follow-ups. Objectives: This study aimed to investigate the clinical efficacy of 99mTc-MIBI washout in patients with AMI by measuring the mean defect area based on 99mTc-MIBI myocardial perfusion-single photon emission computed tomography (MP-SPECT) rest imaging in early and delayed phases and comparing it with the defect area based on 99mTc-MIBI MP-SPECT adenosine stress imaging based on a two-day rest/stress protocol. Patients and Methods: This study was conducted on 29 consecutive patients with AMI (23 males and 6 females; mean age, 71 ± 8.4 years), who underwent MP-SPECT using a standard two-day rest/stress protocol. The rest 99mTc-MIBI MP-SPECT images were acquired in the early phase at one hour after the injection of 99mTc-MIBI and in the delayed phase at three hours after the early phase. The total perfusion deficit (TPD) score for SPECT was measured to compare the defect area between the rest-early phase, rest-delayed phase, and post-stress imaging conditions. Results: Based on the results, the post-stress TPD score was significantly lower than the rest-delayed phase score (TPD: 22.2% ± 14.3% vs. 27.8% ± 14.0%; P &lt; 0.001). Also, the rest-early phase score was significantly lower than the rest-delayed phase score (TPD: 21.5% ± 14.9% vs. 27.8% ± 14.0%; P &lt; 0.001). However, no significant difference was observed between the post-stress score and the rest-early phase score. Conclusion: The combination of rest-early phase, delayed phase, and post-stress 99mTc-MIBI imaging using a two-day protocol after AMI reperfusion was a clinically useful method, which could identify residual ischemia and predict the left ventricular function improvement in the chronic phase of disease while reducing the exposure dose.

The prognostic and diagnostic implications of surveillance serial myocardial perfusion imaging in asymptomatic renal transplant candidates

BackgroundThe utility of serial SPECT myocardial perfusion imaging (MPI) for CAD surveillance in asymptomatic ESRD patients awaiting kidney transplantation (KT) is uncertain. Methods and ResultsWe retrospectively investigated 700 asymptomatic KT candidates with ≥ 2 pre-transplant SPECT-MPIs (mean interval, 20 ± 13 months). Worsening MPI was defined as total perfusion deficit increase (ΔTPD) > 5%. High clinical risk was defined as ≥ 3 AHA/ACC KT risk factors. The primary outcome was major adverse cardiac events (MACE) of cardiac death or myocardial infarction. The initial MPI was normal in 462 (66%) subjects. On repeat MPI, ΔTPD > 5% was observed in 82 (12%) subjects, and the incidence increased with increasing time gap between MPIs (P = .006). During a mean follow-up of 16 ± 8 months, there were 119 (17%) MACEs. In the entire cohort, ΔTPD > 5% was not significantly associated with MACE (HR = 1.38; P = .210). ΔTPD > 5% was associated with increased MACE rate among patients with normal initial MPI (HR = 2.30; P = .005), but not among those with abnormal initial MPI (P = .260). There was a significant interaction between ΔTPD > 5% and initial MPI normalcy status in predicting MACE (interaction P = .018), such that the predictive value of ΔTPD is dependent on the initial MPI normalcy. Among subjects with normal initial MPI, ΔTPD > 5% was significantly associated with MACE only if the sum of KT risk factors was ≥ 3 (HR = 2.26; P = .016). Among 123 patients who underwent coronary angiography, ΔTPD > 5% was associated with a higher prevalence of obstructive CAD when the initial MPI was normal and the sum of KT risk factors was ≥ 3. ConclusionAmong patients with ESRD waitlisted for KT, new/worsening MPI abnormalities are expected. On serial surveillance, ΔTPD > 5% is associated with MACE and obstructive CAD among those with a normal initial MPI and ≥ 3 AHA/ACC KT risk factors.

Deep Capillary Geometric Perfusion Deficits on OCT Angiography Detect Clinically Referable Eyes with Diabetic Retinopathy

To evaluate the sensitivity (SN) and specificity (SP) of OCT angiography (OCTA) parameters for detecting clinically referable eyes with diabetic retinopathy (DR) in a cohort of patients with diabetes mellitus (DM). Retrospective, cross-sectional study. Patients with DM with various levels of DR. We measured vessel density, vessel length density (VLD), and geometric perfusion deficits (GPDs) in the full retina, superficial capillary plexus (SCP), and deep capillary plexus (DCP) on 3× 3-mm OCTA images. Geometric perfusion deficit was recently described as retinal tissue located further than 30 μm from blood vessels, excluding the foveal avascular zone (FAZ). We modified the GPD metric by including the FAZ as an additional variable. Clinically referable eyes were defined as moderate nonproliferative DR (NPDR) or worse retinopathy, or diabetic macular edema (DME). One eye from each patient was selected for the analysis based on image quality. We used a binary logistic regression model to adjust for covariates. Sensitivity, SP, and area under the curve (AUC). Seventy-one of 150 included eyes from 150 patients (52 with DM without DR, 27 with mild NPDR, 16 with moderate NPDR, 10 with severe NPDR, 30 with proliferative DR, and 15 with DME) had clinically referable DR. Geometric perfusion deficit metric that included the FAZ performed better than GPD in detecting referable DR in the SCP (P= 0.025) but not the DCP or full retina (P > 0.05 for both). Deep capillary plexus GPD had the largest AUC for detecting clinically referable eyes (AUC= 0.965, SN= 97.2%, SP= 84.8%), which was significantly larger than the AUC for vessel density of any layer (P < 0.05 for all) but not DCP VLD (P= 0.166). The cutoff value of 2.5% for DCP GPD resulted in a highly sensitive test for detecting clinically referable eyes without adjusting for covariates (AUC= 0.955, SN= 97.2%, SP= 79.7%). Vascular parameters in OCTA, especially in the DCP, have the potential to identify eyes that warrant further evaluation. Geometric perfusion deficits may better distinguish these clinically referable eyes with DR than standard vessel density parameters.

Prognostic value of early left ventricular ejection fraction reserve during regadenoson stress solid-state SPECT-MPI

BackgroundWe hypothesized early post-stress left ventricular ejection fraction reserve (EFR) on solid-state-SPECT is associated with major cardiac adverse events (MACE). Methods151 patients (70 ± 12 years, male 50%) undergoing same-day rest/regadenoson stress 99mTc-sestamibi solid-state SPECT were followed for MACE. Rest imaging was performed in the upright and supine positions. Early stress imaging was started 2 minutes after the regadenoson injection in the supine position and followed by late stress acquisition in the upright position. Total perfusion deficit (TPD) and functional parameters were quantified automatically. EFR, ∆end-diastolic volume (EDV), and end-systolic volume (ESV) were calculated as the difference between stress and rest values in the same position. EFR < 0%, ∆EDV ≥ 5 ml, or ∆ESV ≥ 5 ml was defined as abnormal. ResultsDuring the follow-up (mean 3.2 years), 28 MACE occurred (19%). In Kaplan–Meier analysis, there was a significantly decreased event-free survival in patients with early EFR < 0% (P = 0.004). Similarly, there was a decreased event-free survival in patients with ∆ESV ≥ 5 ml at early stress (P = 0.003). However, EFR, ∆EDV, and ∆ESV at late stress were not associated with MACE-free survival. Cox proportional hazards model adjusting for clinical information and stress TPD demonstrated that EFR, ∆EDV, and ∆ESV at early stress were significantly associated with MACE (P < 0.05 for all). ConclusionsReduced early post-stress EFR on vasodilator stress solid-state SPECT is associated with MACE.

Spectrum of radionuclide perfusion study abnormalities in takotsubo cardiomyopathy

BackgroundTakotsubo (stress) cardiomyopathy (TCM) is characterized by transient apical left ventricular dysfunction precipitated by emotional or physical stress. Its presentation makes it difficult to differentiate from an acute coronary syndrome. A suggestive echocardiogram plus normal coronary angiography most often are used for diagnosis. Radionuclide perfusion study (RPS) findings in TCM, including by positron emission tomography (PET), have been poorly characterized. Methods and ResultsIntermountain Healthcare electronic medical records were searched from 2009 to 2019 for patients with a discharge diagnosis of TCM, stress CM, or takotsubo syndrome. 16 TCM patients with an RPS, including by PET in 8, were identified: 13 (81%) were women; age averaged 72 years (50-89 years); 14 had an identified stressor. TCM diagnosis was definite in 11 and probable/possible in 5. RPS was abnormal in 11, with 9 showing an apical perfusion deficit, whereas angiography in 14 showed normal coronaries in 12 and non-obstructive disease in 2. Echo ejection fraction averaged 41% (29%-60%); an apical wall motion abnormality was present in 14 (88%). Troponin elevations were noted in 14/15. The presenting ECG was abnormal is 14, frequently showing ST-T-wave abnormalities. 13 patients were discharged on a beta-blocker. Follow-up echo (in 12) showed recovered ejection fraction in 9 and recovered apical wall motion in 11. ConclusionsDespite having normal or non-obstructive epicardial coronary arteries on angiography, TCM patients frequently present with apical wall motion abnormalities and matching RPS perfusion defects. These findings suggest microvascular abnormalities, whose pathophysiology, temporal course, and clinical implications should be the subject of further investigation.

Relationship between ischaemia, coronary artery calcium scores, and major adverse cardiovascular events.

Positron emission tomography (PET) myocardial perfusion imaging (MPI) is often combined with coronary artery calcium (CAC) scanning, allowing for a combined anatomic and functional assessment. We evaluated the independent prognostic value of quantitative assessment of myocardial perfusion and CAC scores in patients undergoing PET. Consecutive patients who underwent Rb-82 PET with CAC scoring between 2010 and 2018, with follow-up for major adverse cardiovascular events (MACE), were identified. Perfusion was quantified automatically with total perfusion deficit (TPD). Our primary outcome was MACE including all-cause mortality, myocardial infarction (MI), admission for unstable angina, and late revascularization. Associations with MACE were assessed using multivariable Cox models adjusted for age, sex, medical history, and MPI findings including myocardial flow reserve.In total, 2507 patients were included with median age 70. During median follow-up of 3.9 years (interquartile range 2.1-6.1), 594 patients experienced at least one MACE. Increasing CAC and ischaemic TPD were associated with increased MACE, with the highest risk associated with CAC &gt; 1000 [adjusted hazard ratio (HR) 1.67, 95% CI 1.24-2.26] and ischaemic TPD &gt; 10% (adjusted HR 1.80, 95% CI 1.40-2.32). Ischaemic TPD and CAC improved overall patient classification, but ischaemic TPD improved classification of patients who experienced MACE while CAC mostly improved classification of low-risk patients. Ischaemic TPD and CAC were independently associated with MACE. Combining extent of atherosclerosis and functional measures improves the prediction of MACE risk, with CAC 0 identifying low-risk patients and regional ischaemia identifying high-risk patients in those with CAC &gt; 0.

Progressive Lacunar Strokes: A Predictive Score

Background and PurposeProgressive lacunar syndromes (PLS) occur in up to 20-30% of patients with lacunar strokes, increasing the risk of long term dependency. Our aim is to develop a predictive score to identify patients at high risk of presenting PLS. MethodsWe derived a risk score for PLS in a cohort of consecutive patients (n=187) presenting with one of the five classic lacunar syndromes (LS) and absence of vascular occlusion, perfusion deficit or symptomatic stenosis. A risk score was developed using the coefficients from the logistic regression model, and receiver operating characteristic (ROC) analysis was conducted to assess the prognostic value of the risk score. Sensitivity, specificity and accuracy were estimated for each total point score. ResultsOut of 187 patients included in our sample, 52 (27.8%) presented PLS. Previous history of diabetes mellitus (1 point), diastolic blood pressure at admission (2 points), clinical deficits consistent with a pure motor syndrome (1 point) and asymptomatic intracranial atheromatosis or stenosis in non-symptomatic territory (1 point) were independent predictors for PLS. The estimated area under the ROC curve for this model was 0.77 (95% CI,0.68 - 0.84). ConclusionThis score could be a useful tool in routine clinical practice to predict the occurrence of PLS, allowing the identification of those patients with LS who are at high risk of long term dependency due to early neurological worsening, and who would benefit the most from an intensive treatment.

P411 MINOCA OR NOT MINOCA? THE DECISIVE ROLE OF CARDIAC MAGNETIC RESONANCE IN THE DIFFERENTIAL DIAGNOSIS OF MYOCARDIAL DAMAGE

Abstract Cardiac MRI can facilitate the differential diagnosis of myocardial damage in patients without coronary artery disease. Our case report is about a 50–year–old man who was admitted to the Emergency Department of the Maggiore Hospital in Bologna in October 2021 for oppressive chest pain at rest; previously he had experienced a similar episode but of minor intensity. He had not previous medical records. When the patient arrived at the emergency department chest pain had regressed, blood pressure was elevated (170/110 mmHg). The ECG showed sinus tachycardia at 100 bpm without electrocardiographic abnormalities suggestive of acute ischemia. Cardiac biomarkers were elevated (hsTnI 312 ng / L –&amp;gt; 975 ng / L – n.v. &amp;lt;19.8 ng / L); blood gas analysis showed pH 7.42, pO2 47 mmHg and pCO2 33 mmHg. Chest CT scan excluded pulmonary embolism and acute aortic syndrome. The patient was transferred to Cardiology Ward in the suspicion of acute coronary syndrome, where echocardiogram showed normal biventricular volumes, mild wall hypertrophy and hypokinesia of the lower middle wall (EF 52%). Coronary angiography didn’t showed any obstructive stenosis in any epicardial vessels. In consideration of the clinical presentation and instrumental evidences, the patient was discharged with a diagnosis of myocardial infarction with non–obstructive coronary arteries (MINOCA), but a cardiac MRI was scheduled in the post–discharge to clarify its genesis. MRI didn’t showed any areas of signal hyperintensity, any perfusion deficits in the first pass study and any areas of late gadolinium enhancement (LGE). Those images permitted to exclude areas of necrosis or inflammation, orienting the diagnosis to myocardial damage during hypertensive crisis. Therefore, the antiplatelet therapy recommended at discharge was suspended. In this case report, cardiac magnetic resonance showed that it can improve the etiological diagnosis of MINOCA, allowing for better clinical and therapeutic management.

P116 GIANT LEFT ATRIAL MYXOMA CAUSING ACUTE ISCHEMIC STROKE

Abstract Aims Primary cardiac tumours are rare; most are benign, and around half are myxomas, often located in the left atrium. Clinical presentation is variable. Ischaemic stroke is a rare, although real and potentially fatal, complications of cardiac myxomas. Case Report We present a case of a 51–year–old man, ex– smoker, obese, with history of hypertension and COPD, presented to our emergency department with right–sided hemiplegia and aphasia caused by ischaemic stroke. Brain CT revealed cerebral perfusion deficit. The patient was underwent intravenous thrombolytic strategy. TTE showed a large left atrial mass attached to the interatrial septum, with a friable appearance, suggestive of myxoma. The 2D and 3D TEE detected a giant space–occupying mass in the left atrium, coral–like, and the most apical portion prolapsed into the left ventricle during diastole, causing fixed obstruction to flow in the left ventricular inflow tract. In view of the risk of imminent embolization, the emergent surgical excision of the tumour was performed. Subsequent histopathological findings confirmed the diagnosis of myxoma. Symptomatic cardiac myxoma may present with one of the three classic clinical presentations of the Goodwin’s triad, which include intracardiac obstruction, constitutional symptoms, and embolism. The obstructive pattern mimics atrioventricular valve obstruction. Constitutional manifestations include fatigue, fever, weight loss. Systemic embolization from myxoma occurs in around a third of cases. Of these, the most serious is cerebrovascular embolism, which may result in cerebral stroke. The tumour size, location, and macroscopic appearance, along with mean platelet volume and platelet count, are closely associated with embolic events. Echocardiography remains the method of choice for diagnosis and morphological characterization of myxoma. Two patterns have been established by echocardiography: round, with a solid appearance and a firm surface, and polypoid, with an irregular outline and a friable surface. The incidence of systemic embolization is higher in those with an irregular and friable surface and those that prolapse into the ventricle. Once a diagnosis of myxoma is established, surgical resection is the only effective treatment and should be performed immediately, in view of the risk of embolization. Conclusions With this case report, we stress the importance of echocardiography in new onset of neurological deficit to prevent potentially fatal outcomes.

Tmax profile in computed tomography perfusion-based RAPID software maps influences outcome after mechanical thrombectomy in patients with basilar artery occlusion

BackgroundComputed tomography perfusion (CTP) parameters have been shown to have predictive value for functional outcomes of patients with basilar artery occlusion (BAO). We report the predictive value of CTP-based software...