Recurrent Transient Ischemic Attacks Research Articles

Arterial tortuosity syndrome causing recurrent transient ischemic attacks in young adult: a case report

BackgroundArterial Tortuosity Syndrome (ATS) is a rare autosomal recessive disorder characterized by elongated and tortuous arteries. Although ATS showed a significant clinical and pathophysiological overlap with other syndromes involving connective tissues, only few cases of cerebrovascular events related to this syndrome have been described so far.Case presentationWe report the case of a 33-years-old male diagnosed with ATS since childhood, that experienced three sudden episodes of expressive aphasia and right hemiparesis with spontaneous resolution. He was treated with recombinant tissue plasminogen activator (r-TPA) at a dosage of 0.9 mg/kg with a complete recovery. Brain Magnetic Resonance Imaging (MRI) showed the absence of acute ischemic lesions and the patient was diagnosed with recurrent transient ischemic attacks (TIA).Intracranial and supra-aortic trunks Magnetic Resonance Angiography (MRA) and Angio-CT scan of the thoracic and abdominal aorta showed marked vessel tortuosity without stenosis.To our knowledge, this is the first reported case of an ATS patient with TIA in young age that was treated with intravenous thrombolysis with recombinant plasminogen activator.ConclusionOur report strengthens the relationship between ATS and juvenile cerebrovascular events, suggesting that an extensive study of body vessels in order to detect potential stenoses or occlusions in these cases is needed.The greater predisposition to cerebrovascular events in ATS could benefit from a more aggressive primary and secondary prevention therapy.

The efficacy and safety of insertable cardiac monitor on atrial fibrillation detection in patients with ischemic stroke: a systematic review and meta-analysis.

Atrial fibrillation (AF) leads to a high risk of recurrent stroke, and the insertable cardiac monitor (ICM), as a new kind of electrocardiographic monitoring device, has been proven to enhance the recognition rate of AF. The aim of this systematic review was to evaluate the efficacy and safety of the ICM use in AF detection of patients with stroke. We pooled 1233 patients from three randomized controlled trials (RCTs). The detection rate of AF was superior in the ICM group to that in the control group at 6months (risk ratio [RR], 4.63; P < 0.0001; 95% confidence interval [CI], 2.17-9.90) and 12months (RR, 5.04; P < 0.00001; 95% CI, 2.93 to 8.68). Patients in the ICM group had a higher rate of oral anticoagulant usage (RR, 2.76; P < 0.00001; 95% CI, 1.89-4.02). However, there was no difference in the time to first detection of AF within 12months (mean difference, - 8.28; P = 0.82; 95% CI, - 77.84-61.28) or the rate of recurrent ischemic stroke or transient ischemic attack (RR, 0.88; P = 0.51; 95% CI, 0.60-1.28) between the ICM and control groups. In addition, the ICM group experienced more adverse events than the control group within 12months (RR, 4.42; P = 0.002; 95% CI, 1.69-11.55). To conclude, the sensitivity of ICM is superior to that of conventional external cardiac monitoring. Reducing adverse reactions will be a new development direction of ICM.

Patients Receiving Extracranial to Intracranial Bypass for Atherosclerotic Vessel Occlusion Today Differ Significantly From the COSS Population

A retrospective, single-center study was performed in Berlin between January 2012 and December 2019. A total of 179 patients with atherosclerotic disease (51% with unilateral internal carotid artery [ICA] occlusion; 49% with multivessel disease) had undergone extracranial to intracranial bypass for symptoms that had occurred within the previous 4 months, including recurrent minor ischemic stroke or transient ischemic attack (TIA) in 136 patients (76%), single TIA or ischemic stroke in 36 patients (20%), and hemodynamic instability in 7 patients (4%). The overall perioperative stroke, surgical complication, and 1-year ischemic or TIA event rate was 4%, 6.5%, and 6%, respectively. Patients more recently referred for flow augmentation surgery appear to experience more severe symptoms and have more severe vessel occlusion patterns than did patients reported in the COSS (carotid occlusion surgery study). A new randomized controlled trial appears warranted, considering the poor prognosis of patients with an occluded ICA and associated severe multivessel atherosclerotic cerebrovascular disease.

Atrial High-Rate Episode Duration Thresholds and Thromboembolic Risk: A Systematic Review and Meta-Analysis.

BackgroundAvailable evidence supports an association between atrial high‐rate episode (AHRE) burden and thromboembolic risk, but the necessary extent and duration of AHREs to increase the thromboembolic risk remain to be defined. The aim of this systematic review and meta‐analysis was to identify the thromboembolic risk associated with various AHRE thresholds.Methods and ResultsWe searched PubMed and Scopus until January 9, 2020, for literature reporting AHRE duration and thromboembolic risk in patients with implantable electronic devices. The outcome assessed was stroke or systemic embolism. Risk estimates were reported as hazard ratio (HR) or relative risk alongside 95% CIs. We used the Paule‐Mandel estimator, and heterogeneity was calculated with I2 index. Among 27 studies including 61 919 patients, 23 studies reported rates according to the duration of the longest AHRE and 4 studies reported rates according to the cumulative day‐level AHRE duration. In patients with cardiac implantable devices, AHREs lasting ≥30 seconds significantly increased the risk of stroke or systemic embolism (HR, 4.41; 95% CI, 2.32–8.39; I2, 5.5%), which remained consistent for the thresholds of 5 minutes and 6 and 24 hours. Patients with previous stroke or transient ischemic attack and AHREs lasting ≥2 minutes had a marginally increased risk of recurrent stroke or transient ischemic attack. The risk of stroke or systemic embolism was higher in patients with cumulative AHRE ≥24 hours compared with those of shorter duration or no AHRE (HR, 1.25; 95% CI, 1.04–1.52; I2, 0%).ConclusionsThis systematic review and meta‐analysis suggests that single AHRE episodes ≥30 seconds and cumulative AHRE duration ≥24 hours are associated with increased risk of stroke or systemic embolism.

Meta-Analysis of Randomized Clinical Trials Comparing the Impact of Implantable Loop Recorder Versus Usual Care After Ischemic Stroke for Detection of Atrial Fibrillation and Stroke Risk

Implantable loop recorder (ILR) is recommended to detect subclinical atrial fibrillation (AF) after cryptogenic stroke; however, the clinical outcomes of this practice is unclear. We conducted a systematic review and meta-analysis of randomized controlled trials to evaluate 12-month AF detection, change in oral anticoagulation (OAC), and recurrent stroke in ILR versus usual care after ischemic stroke. We searched Medline, Embase, Web of Science, Cochrane Library for randomized controlled trials comparing ILR with usual care after any ischemic stroke. Primary outcomes were cumulative AF detection and recurrent stroke (ischemic or hemorrhagic) or transient ischemic attack over 12 months. Secondary outcome was OAC initiation. Meta-analysis was performed with Mantel-Haenszel pooled odds ratios (ORs) and random effects models. Of 200 identified articles, 3 trials were included (1,233 participants). Cryptogenic stroke and underlying AF included cryptogenic stroke only, stroke of known cause and underlying-AF included small or large vessel stroke only, and post embolic rhythm detection with implantable vs external monitoring included all ischemic strokes. The 12-month AF detection was 13% in the ILR group and 2.4% in controls. ILR was more likely to detect AF compared with usual care (OR 5.8, 95% confidence interval 3.2 to 10.2). Stroke or transient ischemic attack occurred in 7% with ILR and 9% with usual care (OR 0.8, 95% confidence interval 0.5 to 1.2). In patients with detected AF, 97% and 100% were started on OAC in cryptogenic stroke and underlying AF and post embolic rhythm detection with implantable vs external monitoring, respectively, compared with 68% in stroke of known cause and underlying-AF. In conclusion, ILR was superior to usual care in AF detection, but the relative low incidence of AF and the nondifferential risk of stroke between the ILR and usual care arms may suggest that most patients do not benefit from ILR implantation. Further studies are warranted to understand if patient selection can be improved to increase the diagnostic yield of ILR.

Atrial cardiopathy predicts detection of atrial fibrillation in embolic stroke of undetermined source: real-life data.

Atrial cardiopathy (AC) is more frequent in patients with embolic stroke of undetermined source (ESUS) than in patients with non-cardioembolic stroke. The aim of this work was to describe AC in patients with ESUS and to study its impact on detection of atrial fibrillation (AF) during follow-up. This is an observational study of 123 consecutive ESUS patients and 55 ESUS patients from a previous cohort. AC was defined according to the presence of one or more of the following criteria: severe left atrial enlargement, p-wave terminal force in lead V1 > 5000 μVxms, and excessive premature atrial complexes. Unadjusted and adjusted survival analyses for the occurrence of AF and stroke or transient ischemic attack (TIA) were performed. Diagnostic performance of AC for the detection of AF was analyzed. Among 178 patients with ESUS, those with AC (42.7%) were older (p < 0.001), and more frequently had hypertension (p = 0.001) and lower total cholesterol levels (p = 0.001) than patients without AC. The detection of AF during follow-up (median 34months, interquartile range = 12.8-64) was higher in patients with AC (hazard ratio = 7.00, 95% confidence interval = 2.01-24.39, p = 0.002). This association persisted after adjusting for age, arterial hypertension, and other vascular risk factors. The c-statistic for detection of AF during follow-up for AC was 0.719. There were no differences in stroke or TIA recurrence between groups with and without AC. ESUS patients with AC have different baseline clinical characteristics than patients without AC and have a higher detection of AF during follow-up.

Safety, feasibility and efficacy of metformin and sitagliptin in patients with a TIA or minor ischaemic stroke and impaired glucose tolerance

IntroductionImpaired glucose tolerance (IGT) is highly prevalent after stroke and is associated with recurrent stroke and unfavourable outcome.ObjectivesWe aimed to assess the feasibility, safety and effects on glucose metabolism of...

Cortical thickness in clinical moyamoya disease: A magnetic resonance imaging study.

Moyamoya disease (MMD) is a progressive cerebrovascular disorder, with an unknown pathogenesis and aetiology. MMD is characterized by steno-occlusive changes at the terminal portion of the internal carotid artery (ICA), which is accompanied by variable development of the basal collaterals, also known as moyamoya vessels. Patients with MMD show variable patterns of brain damage and may experience recurrent multiple transient ischaemic attacks, intracranial bleeding and cerebral infarction. In this study, we investigate the potential for structural T1 magnetic resonance imaging (MRI) to help characterize abnormal cortical development in MMD clinically, with an analysis of both average and variability of regional cortical thicknesses. This study also included a machine learning analysis to assess the predictive capacity of the cortical thickness abnormalities observed in this research. This study included 993 MRI examinations from neurotypical controls and 269 MRI examinations from MMD patients. Results demonstrate abnormal cortical presentation of the insula, caudate, postcentral, precuneus and cingulate regions, in agreement with previous literature cortical thickness findings as well as alternative methods such as functional MRI (fMRI) and digital angiography. To the best of our knowledge, this is the first manuscript to report cortical thickness abnormalities in the middle temporal visual area in MMD and the first study to report on cortical thickness variability abnormalities in MMD.

The Course of Carotid Plaque Vulnerability Assessed by Advanced Neurosonology.

Background: Carotid artery atherosclerosis is a major risk factor for ischemic stroke. This risk is related to plaque vulnerability and is characterized by plaque morphology, intraplaque neovascularization, and cerebral microembolization. Advanced neurosonology can identify vulnerable plaques and aid in preventing subsequent stroke. We aimed to assess the time course of cerebral microembolization and intraplaque neovascularization during 6 months of follow-up and to explore the utility of advanced neurosonology in patients with acute cerebral ischemia.Methods: Fifteen patients with acute cerebral ischemia and carotid artery plaques underwent comprehensive extra- and intracranial ultrasound examinations, including microemboli detection and contrast-enhanced ultrasound. The examinations were repeated after 3 and 6 months.Results: We examined 28 plaques in 15 patients. The ultrasonographic features of plaque vulnerability were frequent in symptomatic and asymptomatic plaques. There were no significant differences in stenosis degree, plaque composition, plaque surface, neovascularization, or cerebral microembolization between symptomatic and asymptomatic plaques, but symptomatic plaques had a higher number of vulnerable features. None of the patients had recurrent clinical stroke or transient ischemic attack during the follow-up period. We observed a decrease in cerebral microembolization at 6 months, but no significant change in intraplaque neovascularization.Conclusions: In patients with acute cerebral ischemia and carotid artery plaques, cerebral microembolization decreased during 6 months of follow-up, indicating plaque stabilization.Clinical Trial Registration:ClinicalTrial.gov, identifier NCT02759653.

Safety and efficacy of balloon-mounted stent in the treatment of symptomatic intracranial atherosclerotic disease: a multicenter experience

BackgroundRandomized clinical trials have failed to prove that the safety and efficacy of endovascular treatment for symptomatic intracranial atherosclerotic disease (ICAD) is better than that of medical management. A recent...

From the clinical spectrum of myocardial calcification to a cardiovascular imaging perspective

We herein report the case of a 74-year-old man with recurrent transient ischemic attacks and falls who was found to have an unusual large mass of the interventricular septum. After extensive workup, isolated myocardial calcification was confirmed using multimodality cardiovascular imaging. This rare finding might be a reflecting cause of the patient’s clinical presentation.

Recurrent Transient Ischemic Attack Followed By Stroke Due To Stretched Patent Foramen Ovale – A Rare Entity

A Patent Foramen Ovale (PFO) is not a true deficiency of atrial septal tissue but rather a potential space or separation between the septum primum and septum secundum located in the anterosuperior portion of the atrial septum. It is not considered a true Atrial Septal Defect (ASD), because no structural deficiency of the atrial septal tissue is present. We are describing a unique case of recurrent transient attacks followed by stroke associated with finding of a large stretched PFO on echocardiography.

Short and Long-Term Risk of Major Cardiovascular Events after Ischemic Stroke or Transient Ischemic Attack in Myeloproliferative Neoplasms

BACKGROUND. Very few previous studies have estimated the risk of recurrence after cerebral transient ischemic attack (TIA) or ischemic stroke (IS) in patients with myeloproliferative neoplasms (MPN). PRISM (Preventing Ischemic Stroke in Myeloproliferative Neoplasms) is an international investigator-driven study with three purposes: (1) to describe the clinical profile at presentation of ischemic TIA/IS in contemporary patients with polycythemia vera (PV), essential thrombocythemia (ET) and primary myelofibrosis (PMF); (2) to evaluate the short and long-term outcomes beyond the acute phase and to explore their comparability with non MPN population; (3) to refine the risk assessment for recurrences and cardiovascular mortality.METHODS. From January 2005 through December 2015, 597 patients with objectively proven TIA (n= 270) or IS (n=327) at 22 sites of 5 countries were enrolled. We estimated the 1- and 5-year risk of composite cardiovascular (CV) outcome, including recurrent TIA, IS, myocardial infarction (AMI) and CV deaths, and analyzed the incidence of each single outcome by competing risk method.RESULTS. The distribution of single MPN and baseline blood counts were similar in IS and TIA groups; atrial fibrillation was observed in a minority of cases (4% TIA and 7% IS) as compared with the general population (11-18% and 20%-30%, respectively); other comorbidities were approximately half of those of non-MPN patients [ Weimar C et al, Arch Neurol 2002;59:1584; Buchwald F et al, Stroke 2016;47:2456; Amarenco P et al, N Engl J Med 2016;374:1533 ]; a substantial proportion of TIA cases had a higher history of microvascular disturbances while arterial hypertension was more frequent in IS than TIA. Secondary prophylaxis included aspirin, oral anticoagulants and cytoreductive therapy.After one year since the TIA index event, the incidence of cumulative outcome was 4.21%. However, no IS happened in the first 2 years after TIA and this event after 5 years happened in only 1.24% of cases. The corresponding incidence in the general population was 4.4% to 5.1% after one year and 12-16% after 5 years [ Weimar C et al, Arch Neurol 2002;59:1584; Buchwald F et al, Stroke 2016;47:2456; Amarenco P et al, N Engl J Med 2016;374:1533 ]. In contrast, new TIA episodes progressively increased year by year reaching 12% incidence after 5 years.After the IS index event, new strokes occurred with cumulative incidence lower than in the general population: after 1 and 5 years, the incidence was 2.03% and 6.52% vs 11.1%-12% and 26.4% of non-MPN patients [ Mohan KM et al, Stroke 2011;42:1489; Bergstrom L et al, Stroke 2017 Jul 13, AOP ]. The rate of deep venous thrombosis (DVT) in the first year, was higher after index IS than TIA, but was the same by 5 years (3.68% and 4.60%, respectively; p=0.47).Predictors of recurrent TIA and IS were the same index events (HR=2.41 and 4.41), and for recurrent TIA the remote history of cerebrovascular TIA episodes (HR=3.40) and microvascular disturbances (HR=2.30). Other prognostic factors of recurrent IS were arterial hypertension (HR=4.24) and occurrence of IS during the course of MPN (HR=4.27). On the contrary, cytoreductive therapy emerged as a strong protective factor able to reduce the probability of new strokes in 76% of patients (HR=0.24). The history of peripheral thrombosis, both venous and arterial events, independently predicted the occurrence of AMI (HR=6.30), while age over 60 years (HR=3.98), index IS (HR=3.61), occurrence after MPN diagnosis (HR=2.62), were all prognostically significant for CV mortality. During median follow-up of 4.2 years, major bleeding occurred with a frequency similar to that observed in the general population receiving long-term antiplatelet secondary prophylaxis (0.90 % pts/year) [ Li L et al, Lancet 2017 Jun 13, AOP ].CONCLUSION. Current antithrombotic therapy and cytoreductive drugs after index TIA and IS led to a reduction of cardio-vascular recurrences and mortality in a proportion of MPN patients greater than in general population. This would indicate that ischemic cerebral vascular events recognize a specific pathogenesis of thrombosis linked to the clonal disorder. Although the benefit-risk profile of secondary prophylaxis appears favorable, some high risk categories need new intervention strategies to be defined in prospective studies. DisclosuresIurlo:Novartis: Consultancy, Honoraria; Bristol Myers Squibb: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria. Finazzi:Italfarmaco S.p.A.: Consultancy. Bonifacio:Incyte: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees, Research Funding; Pfizer: Membership on an entity's Board of Directors or advisory committees; Bristol-Myers Squibb: Membership on an entity's Board of Directors or advisory committees. Gaidano:Gilead: Consultancy, Honoraria; Roche: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; AbbVie: Consultancy, Honoraria; Janssen: Consultancy, Honoraria. Vannucchi:Shire: Speakers Bureau; Novartis: Honoraria, Speakers Bureau.

Power of Hypoperfusion in Predicting Recurrent Transient Ischemic Attacks: Protocol of a Prospective Cohort Study.

Background: Transient ischemic attack (TIA) has a high incidence of recurrent vascular events. Hypoperfusion is one of the factors that are closely correlated with 7-day recurrence of TIA. This study aimed to evaluate the power of hypoperfusion shown on magnetic resonance (MR) perfusion imaging in predicting the incidence of 7-day recurrence of ischemic events after TIA.Methods/Design: REATTACK is a prospective multi-centered cohort study on the correlation between MR perfusion and TIA recurrence. Ninety patients aged ≥18 years with recent (<7 days after onset) clinical TIA will be continuously included. All the patients will undergo diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI) assessments within 24 h after the onset of TIA. The subjects will then be divided into a PWI positive group and a PWI negative group according to the time-to-maximum of the residue function (Tmax). PWI will be repeated after 7 days and in 3 months. The primary clinical outcome will be the recurrence of TIA within 7 days after the onset of TIA. Secondary outcomes will be the recurrence of TIA in 3 months and modified Rankin scale (mRS) score. A chi-square test will be performed to compare the difference in the incidence of recurrent TIA between the two groups, and rank sum test in the mRS score. Multivariate logistic regression will be simultaneously performed to analyze the risk factors for the recurrence of TIA.Discussion: The results of this study will confirm whether abnormal Tmax helps to identify the patients with TIA who have high risks of recurrent ischemic events. This would largely improve the prognosis of patients with TIA.Trial Registration: www.chictr.org.cn, registration number: ChiCTR2000031863, registered on 12 April 2020.

Recanalization of symptomatic chronic internal carotid artery occlusions by hybrid treatment

ObjectiveTo evaluate the efficacy and safety of hybrid revascularization by carotid endarterectomy and endovascular intervention in the treatment of chronic internal carotid artery occlusion (ICAO). MethodsWe performed a retrospective analysis of patients who received hybrid treatment for symptomatic chronic ICAO between December 2016 and December 2018. Fifty-six patients with long-segment ICAO were enrolled and divided into the short duration (1–3 months) and long ICAO duration (>3 months) groups, and their clinical and angiographic data were analyzed. ResultsThe mean duration was 106.8 ± 36.1 days from the date of ICAO diagnosis to revascularization. Totally, 10 patients (17.8%, n = 56) in the short duration group while no patients in the long duration group failed recanalization (n = 7). Perioperative complications included intraoperative thromboembolism in 1 (1.8%) patient and subarachnoid hemorrhage in 2 (3.6%) patients. Early phase postoperative hypertension was noted in 11 (19.6%) patients and cervical hemorrhage in 1 (1.8%) patient. No severe neurological deficits occurred. Overall, the 6-month modified Rankin score, Mini-mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) scores in patients with successful recanalization significantly improved versus the baseline (P < 0.05). After successful recanalization, the long duration group demonstrated more stents for revascularization compared with the short duration group (P < 0.05). Five (10.8%) patients had recurrent transient ischemic attack, and 1 (2.2%) patient developed stroke in the successful revascularization group during 6 months of follow-up. ICA restenosis occurred in 5 (8.9%) patients and re-occlusion was noted in 1 (1.8%) patient. ConclusionsHybrid operation may be feasible and effective for patients with symptomatic chronic complete ICAO according to our limited data. The original occlusion site from the carotid bifurcation and the duration of ICAO should be considered as independent indicators for successful recanalization as well as perioperative outcomes.

A case report of moyamoya disease in children treated with encephalo-duro-myo-arterio-pericranial synangiosis

Moyamoya disease that manifests during childhood may pose a special challenge for surgeons. We report a case of a 10-year-old girl who suffered from moyamoya disease and was successfully treated with encephalo-duro-myo-arterio-pericranial synangiosis (EDMAPS). She presented with a recurrent transient ischemic attack that worsened for 1 year. She was aphasic globally (sensory and motor) and had slightly weak right extremities. Her magnetic resonance angiography and computed tomography angiography showed the typical features of moyamoya disease with bilateral stenosis at the terminal internal carotid artery, bilaterally abnormal vascular networks, and a left ischemic event involving the temporoparietal region. She was recovered well after underwent bilateral EDMAPS, fully regained her language function after 3 months, and gathered her strength back. Therefore, EDMAPS could be a good, safe, and effective treatment for moyamoya disease in children.

Effects of the Vertebral Artery Ostium/Subclavian Artery Angle on In-Stent Restenosis after Vertebral Artery Ostium Stenting

Methods Between January 2016 and October 2018, sixty-four consecutive patients who underwent a total of 66 stenting procedures were screened for symptomatic and asymptomatic atherosclerotic VAOS. Of these patients, 57 had complete follow-up data. The baseline patient demographics and morphological features of the VAO were recorded. Potential factors influencing ISR, including conventional cerebrovascular disease risk factors, were assessed, together with outcome events including recurrent transient ischemic attack (TIA), stroke, and vascular-related mortality. Results The average follow-up period was 13.2 ± 4.6 months. Technical success was achieved in all interventions. The degree of stenosis was reduced from 77.2 ± 6.1% to 13.7 ± 8.9% after the procedure. ISR was detected in eight treated vessels (14.0%) and occlusion in two (5.3%) arteries. Of the 57 patients, one had an ischemic stroke and 5 had TIAs. The angle of the VAO at the subclavian artery was associated with the risk of restenosis (preoperative, P = 0.04; postoperative, P = 0.02). Conclusions Stenting is a feasible and effective treatment for VAOS. The angle of the VAO at the subclavian artery may contribute to the development of ISR.

Schizophrenia likely related to be with cadasil: A case report

IntroductionCADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy) is an inherited disease caused by mutations in the Notch3 gene in chromosome 19.The clinical features are primarily neurological, which include recurrent transient ischaemic attacks, strokes, and migraines.However, psychiatric manifestations such as severe depression, psychosis, changes in behavior and personality have also been reported in CADASIL. Symptoms and disease onset vary widely, with signs typically appearing in the mid-30s.Some individuals may not show signs of the disease until later in life.ObjectivesIn this case report, we present a possible case of CADASIL, a 67-year old female patient diagnosed with schizophrenia fifteen years ago to discuss the co-occurrence of these conditions in the light of the literature.MethodsHospitalization records of the patient viewed.ResultsOur patient suffered from sleep disturbances, hearing religious voices and in psychiatric examination resistant to treatment psychotic symptoms such as blunted affect, mystic, persecutory delusions, auditory hallucinations were present.Cranial magnetic resonance imaging scan was performed and revealed leukoencephalopathy, high-signal intensity lesions in the periventricular white matter consistent with a diagnosis of CADASIL.Atypical antipsychotics found to be effective in treating psychotic symptoms in our case.ConclusionsPersistent psychotic symptoms despite adequate antipsychotic treatment in patients diagnosed with schizophrenia, also with pathological findings in MRI an organic cause such as CADASIL must be considered. Further studies are needed to better understand the exact impacts of cerebral tissue lesions and psychiatric symptoms in CADASIL patients.DisclosureNo significant relationships.

Prevalence and site of predilection of carotid webs focusing on symptomatic and asymptomatic Japanese patients.

Carotid webs (CWs) have increasingly been recognized as a cause of recurrent ischemic stroke. However, the natural history and clinical course of CWs remain unclear. The authors aimed to clarify the prevalence, imaging features, and optimal treatment of CWs in a Japanese cohort study. A series of 444 consecutive Japanese patients who had undergone CTA of the head and neck between April 2011 and October 2016 was retrospectively reviewed. CW was diagnosed on CT angiograms as a membrane-like intraluminal filling defect along the posterior wall of the carotid bulb or the origin of the internal carotid artery (ICA) on oblique sagittal images and a corresponding thin septum on axial images. Two patients with CWs were identified among 132 patients with suspected stroke. The prevalence of CWs among symptomatic patients with suspected stroke was 1.5%. The prevalence of asymptomatic CWs was 2.2% (7 of 312 cases). The CWs were located in the posterior wall of the carotid bulb in 7 patients and just distal to the ICA origin in 2 patients. There were no apparent differences in the location or lesion length between symptomatic and asymptomatic CWs. Four of the 7 asymptomatic CWs remained asymptomatic for at least 2 years of follow-up. Two patients with symptomatic CWs developed recurrent cerebral infarction and transient ischemic attack despite being on a regimen of oral antiplatelet agents, and carotid endarterectomy was performed as radical treatment. Patients with CWs were younger than controls (median age 55 vs 69 years, p = 0.003) and were less frequently male than controls (33% vs 72%, p = 0.025). CW cases showed significantly fewer common atherosclerosis risk factors than the control group (p < 0.05). Although limited to CTA patients, this study reported on the prevalence and common site of CWs, focusing on symptomatic and asymptomatic Japanese patients. Extensive cross-sectional and prospective observational studies are warranted to elucidate the overall prevalence and natural history of CWs.

Dual-center experiences with interventional closure of patent foramen ovale: A medium-term follow-up study comparing two patient groups aged under and over 60 years.

BackgroundCurrent guidelines recommend interventional closure of patent foramen ovale (PFO) in patients with cryptogenic ischemic stroke who are under 60 years of age.HypothesisThe hypothesis of this study was to compare follow‐up results of PFO closure in patients over 60 years of age to those of patients under 60 years of age in order to determine whether the procedure is safe and effective for both age groups.MethodsWe included 293 patients who had a cryptogenic ischemic stroke and a PFO confirmed by transesophageal echocardiography (TEE) and who were scheduled for percutaneous closure of the PFO between 2014 and 2019. The device implantation was completed in all patients using an Amplatzer™, Occlutec™, or Cardia Ultrasept PFO occluder.ResultsFollow‐up TEE examinations were performed at intervals of 1, 3, and 6 months after implantation. Patients were followed for a median of 3.6 ± 1.2 years. Recurrent ischemic stroke or transient ischemic attack, cardiac death, arrhythmias, and residual shunt were reported equally in both groups.ConclusionsInterventional closure of PFO can be as safe and effective in patients over 60 years of age as it is in patients under 60 years of age regardless of the device used. In this older patient group, rigorous discussion and a case‐by‐case decision‐making process including cardiologists and neurologists is warranted to ensure optimal procedure selection.