Stroke In Such Patients Research Articles

The value of revascularisation of atherosclerotic lesions of the innominate artery at the asymptomatic stage of the disease

To analyze the natural course of asymptomatic atherosclerotic lesions of the innominate artery and to study the long-term results of surgical interventions performed at the asymptomatic stage and to compare them with similar results at the symptomatic stage of the disease. The analysis of the natural course of the disease was performed in 74 asymptomatic patients who were divided into 3 groups depending on the initial degree of severity of the stenosis of the innominate artery: insignificant stenoses (less than 50%), moderate stenoses (50-69%) and haemodynamically significant lesions (70% and more). The analysis of the long-term results of surgical treatment was performed in 62 patients, in 29 of whom intrathoracic reconstructions were performed at the asymptomatic stage of the disease, in 33 - at the symptomatic stage. Cumulative freedom from stroke by the 10th year of follow-up was significantly higher in patients with insignificant stenoses and amounted to 100% in the groups of moderate stenoses and hemodynamically significant lesions - 25% and 0, respectively (log-rank p=0.000). Neurological fatality in patients with hemodynamically significant (initial or developed) lesions was 26.3%, while in patients with hemodynamically insignificant lesions it was 0 (log-rank p=0.004), which is confirmed by cumulative indices (log-rank p=0.008). Asymptomatic innominate artery reconstructions were associated with a lower incidence of stroke: the long-term incidence of stroke in such patients was 3.4%, while in initially symptomatic patients it was 18.2% (p=0.038). Initial degree II or IV cerebrovascular insufficiency was a predictor of stroke in the long-term period (OR=1.71; p=0.000). The cumulative freedom from stroke in asymptomatic patients by the 20th year of follow-up was 95% compared with 74% in symptomatic patients (log-rank p=0.032). Surgical interventions in asymptomatic hemodynamically significant lesions of the innominate artery should be performed to prevent primary cerebral circulatory disorders.

The Antipsychotic Risperidone Alters Dihydroceramide and Ceramide Composition and Plasma Membrane Function in Leukocytes In Vitro and In Vivo.

Atypical or second-generation antipsychotics are used in the treatment of psychosis and behavioral problems in older persons with dementia. However, these pharmaceutical drugs are associated with an increased risk of stroke in such patients. In this study, we evaluated the effects of risperidone treatment on phospholipid and sphingolipid composition and lipid raft function in peripheral blood mononuclear cells (PBMCs) of older patients (mean age >88 years). The results showed that the levels of dihydroceramides, very-long-chain ceramides, and lysophosphatidylcholines decreased in PBMCs of the risperidone-treated group compared with untreated controls. These findings were confirmed by in vitro assays using human THP-1 monocytes. The reduction in the levels of very-long-chain ceramides and dihydroceramides could be due to the decrease in the expression of fatty acid elongase 3, as observed in THP-1 monocytes. Moreover, risperidone disrupted lipid raft domains in the plasma membrane of PBMCs. These results indicated that risperidone alters phospholipid and sphingolipid composition and lipid raft domains in PBMCs of older patients, potentially affecting multiple signaling pathways associated with these membrane domains.

COVID-associated ischemic stroke

Generalization of the fi rst results of treatment of victims of coronavirus infection showed that the development of ischemic stroke in such patients is very likely. An analysis of the few available publications that mention the problem of COVID-associated ischemic stroke has shown that cerebral ischemia can be associated with infl ammation of large arteries and coagulopathy. Anticoagulation with low-molecular-weight heparins should be considered the most eff ective way to prevent a particular pathogenetic subtype of ischemic stroke.

1138 OSA In A Patient With PFO, Is It The “Perfect Storm” For A Stroke? A Case Series Of 3 Patients With Stroke At Young Age, Due To PFO And Comorbid OSA

Abstract Introduction Approximately 25% of all strokes are cryptogenic in nature, and about 50% of all young patients with cryptogenic stroke are found to have patent foramen ovale (PFO), which is known to be the most common cause of right-to-left shunting (RTLS). Studies have shown a 2.2-fold increase in right-to-left shunt in patients with OSA and PFO, compared to patients with PFO alone. Hence, increasing the risk of cardio-embolic stroke in such patients. We present a case series of 3 patients with PFO that had embolic stroke at a young age and were found to have comorbid OSA, the likely exacerbating factor of a RTLS. Methods A 38-year old female, a 59-year old male, and a 27-year old female presented with stroke-like symptoms without clear vascular pathology. Upon further work-up, all were found to have PFO with RTLS. Subsequently, these patients were referred for sleep evaluation, and each one was found to severe REM-related OSA with prominent oxygen desaturations. All three patients were started on PAP therapy for control of their OSA. Two out of the 3 patients opted for PFO closure, and the 3rd patient opted for anti-platelet therapy alone. He has had no recurrence of TIA/stroke after 12 years so far. Results These cases illustrate a correlation between right-to-left shunting and severe REM-related OSA, through possible elevation of right-sided pressure due to nocturnal desaturations/hypoxemia. Hence, it is worth consideration that the increased right-sided pressure induced by apneic events in sleep may be a potential exacerbating factor in producing stroke-like symptoms sooner in patients with PFO than in patients with PFO who are without OSA. Conclusion It may be beneficial to assess young patients with stroke due to PFO, for comorbid OSA as a cause of the RTLS. This would help to prevent recurrent stroke in such patients and improve quality of life. Support No financial support.

Predictors of a Cerebrovascular Accident in a Population of Systemic Sclerosis Patients Followed at a Large Academic Center with a Dedicated Scleroderma Center

Aim: The aim of this study is to describe the clinical characteristics of patients with a diagnosis of systemic sclerosis who later suffer a stroke and to identify associations for this relationship. Background: Prior studies have showed an increased risk of cardiovascular disease among patients with chronic inflammatory disorders, with chronic inflammation leading to atherosclerosis believed to be the culprit. Systemic sclerosis (SSc) is a chronic inflammatory disease characterized by diffuse fibrosis of the skin and internal organs. Previous studies have suggested a possible link between systemic sclerosis and macrovascular complications such as stroke. Methods: This is a retrospective chart review of patients treated within the University of Pennsylvania Health System from October 2015 to April 2019 with a diagnosis of SSc. Using ICD10 codes, we identified a cohort of SSc patients who suffered a stroke. Information regarding demographics and stroke risk factors were gathered from the charts of patients with a diagnosis of both SSc plus stroke and compared to a control group of randomly selected patients with SSc who never suffered a stroke. Continuous variables were conveyed using a mean plus a standard deviation. A two-sample t-test was used to compare the two groups of patients. Qualitative variables were compared using a two-tailed Fisher’s exact test. Results: Based on a large cohort of SSc patients (n = 2080) followed between October 2015 and April 2019, we identified 36 SSc patients who developed a subsequent stroke (1.7% of cohort). When looking at risk factors for stroke in SSc patients, we identified hypertension and atrial fibrillation to be associated with the diagnosis of stroke in such patients. Specifically, 28 of the 36 patients with both SSc and stroke also had a diagnosis of hypertension while in the control group, only 17 of 36 patients had hypertension. Atrial fibrillation was seen in 9 of 36 patients with both SSc and CVA while it was seen in only 2 of 36 patients in the control group. Conclusions: This case control study demonstrated that the presence of hypertension and atrial fibrillation had a statistically significant association with the diagnosis of CVA in patients with SSc.

Secondary Prevention with Antithrombotic Therapies in Stable Ischemic Heart Disease Patients: a Review.

Stable and unstable ischemic heart disease are a growing component in all facets of healthcare, including ER visits, hospitalizations, and financial costs. With the changing emphasis of healthcare shifting towards the outpatient setting, the onus is on clinicians to appropriately manage such patients to avoid adverse effects and complications. Antithrombotic medications, including aspirin, P2Y12 inhibitors, and rivaroxaban, are currently prescribed or have potential roles in the management of secondary cardiovascular prevention in ischemic heart disease patients. While the majority of studies and findings involve aspirin and clopidogrel, newer oral anticoagulation drugs are arriving, prompting new research to assess their impact on preventing mortality, myocardial infarction, and stroke in such patients. Aspirin has a well-established history of safety and efficacy in management of secondary cardiovascular protection in ischemic heart disease patients. A dual-antiplatelet regimen, most commonly including aspirin plus clopidogrel, has been documented to be effective as well in achieving the same goals. Newer agents, such as rivaroxaban, are being analyzed to see if there is scope to include these agents for secondary prevention. One recent study, the COMPASS trial, revealed the major concern of these newer medications: while better cardiovascular outcomes were achieved in subjects on aspirin plus rivaroxaban, this was accomplished in the setting of a higher rate of major bleeding events. In conclusion, the evidence thus far has not been significant enough for the American College of Cardiology to recommend the incorporation of oral anticoagulants in the management of stable ischemic heart disease patients, in contrast to aspirin and clopidogrel. As the antithrombotic and antiischemic properties of these newer agents seem evident, so does their potential for increase in risk of bleeding events. Doctors have to individually tailor antithrombotic medication decisions based on the patient's risk-benefit profile.

Hemodynamics and stroke risk in intracranial atherosclerotic disease.

To investigate whether hemodynamic features of symptomatic intracranial atherosclerotic stenosis (sICAS) might correlate with the risk of stroke relapse, using a computational fluid dynamics (CFD) model. In a cohort study, we recruited patients with acute ischemic stroke attributed to 50 to 99% ICAS confirmed by computed tomographic angiography (CTA). With CTA-based CFD models, translesional pressure ratio (PR = pressurepoststenotic /pressureprestenotic ) and translesional wall shear stress ratio (WSSR = WSSstenotic - throat /WSSprestenotic ) were obtained in each sICAS lesion. Translesional PR ≤ median was defined as low PR and WSSR ≥4th quartile as high WSSR. All patients received standard medical treatment. The primary outcome was recurrent ischemic stroke in the same territory (SIT) within 1 year. Overall, 245 patients (median age = 61 years, 63.7% males) were analyzed. Median translesional PR was 0.94 (interquartile range [IQR] = 0.87-0.97); median translesional WSSR was 13.3 (IQR = 7.0-26.7). SIT occurred in 20 (8.2%) patients, mostly with multiple infarcts in the border zone and/or cortical regions. In multivariate Cox regression, low PR (adjusted hazard ratio [HR] = 3.16, p = 0.026) and high WSSR (adjusted HR = 3.05, p = 0.014) were independently associated with SIT. Patients with both low PR and high WSSR had significantly higher risk of SIT than those with normal PR and WSSR (risk = 17.5% vs 3.0%, adjusted HR = 7.52, p = 0.004). This work represents a step forward in utilizing computational flow simulation techniques in studying intracranial atherosclerotic disease. It reveals a hemodynamic pattern of sICAS that is more prone to stroke relapse, and supports hypoperfusion and artery-to-artery embolism as common mechanisms of ischemic stroke in such patients. Ann Neurol 2019;85:752-764.

Cerebral Vasoreactivity in Children with Sickle Cell Disease: A Transcranial Doppler Study

BackgroundImpairment of vasodilatory capacity reflecting reduced cerebrovascular reserve was previously shown in adults with sickle cell disease (SCD) and might play a role in the pathophysiology of stroke in such patients. We examined the hypothesis that children with SCD would also have a higher frequency of impaired cerebral vasoreactivity when compared with healthy age- and gender-matched controls. MethodsPatients were recruited from our hematology outpatient clinic. All SCD patients aged 10-18 years without a history of symptomatic stroke as well as age- and gender-matched healthy children were evaluated with transcranial Doppler (TCD) ultrasonography, with breath-holding maneuver. Breath-holding index (BHI) was calculated by dividing the percentage increase in mean flow velocity occurring during breath holding by the length of time subjects hold their breath after a normal inspiration. BHI was considered abnormal if less than .69. ResultsTCD was performed in 42 patients (mean age 12.7 ± 2.2 years) and 20 controls (mean age 13.90 ± 3.04 years). Blood flow velocities were higher in patients with SCD than in controls in all arteries evaluated (P < .001). BHI values in patients with SCD were significantly lower than in control subjects (1.27 ± .65 versus 1.74 ± .15, P = .013 on the left and 1.16 ± .45 versus 1.61 ± .11, P = .002 on the right). BHI was abnormal in 19% of the patients and in none of the controls, P = .036. ConclusionsChildren with SCD may have impaired cerebral vasoreactivity, with low BHI values suggesting a reduced autoregulation capacity.

Collateral circulation alters downstream hemodynamic stress caused by intracranial atherosclerotic stenosis

Objectives: Fractional flow reserve (FFR) accurately predicts the degree of stenosis and is now widely used to identify clinically significant severe coronary artery lesions. In the current study, we utilized a similar indicator, fractional flow (FF), to determine the hemodynamic impact of symptomatic intracranial atherosclerotic stenosis (ICAS) and to assess the correlation of FF with the severity of stenosis and collateral circulation.Methods: Patients with symptomatic ICAS (70–99% stenosis) confirmed on digital subtraction angiography (DSA) were consecutively recruited. FF was obtained during DSA examination with the use of pressure sensors and was measured as a ratio, comparing measurements distal to an ICAS lesion (Pd) and within the aorta (Pa). The degree of leptomeningeal collateralization was graded from zero (absent) to four (complete compensatory). The correlation between FF, anatomical stenosis, and collateral status was then analyzed.Results: Twenty-five patients with a mean age of 55.6 years were analyzed. The median percentage of stenosis and median FF were 82.3 and 0.68%, respectively. Eleven patients were found to have poor collateralization (grade 0-2), and fourteen patients were identified with good collateral circulation (grade 3-4). Overall, the hemodynamic impact of an atherosclerotic lesions worsened (decreased FF) as the percentage of stenosis increased, although this did not reach statistical significance (r = −0.398, p = 0.06). However, the status of collateralization significantly altered this correlation, worsening the hemodynamic impact in patients with poor collateral circulation (r = −0.677, p = 0.032). There was no difference in patients with good collateral circulation (r = −0.279, p = 0.356).Conclusion: An anatomically severe (70–99%) symptomatic ICAS lesion may generate significant hemodynamic stress downstream as assessed by the indicator FF, particularly in patients with poor collateral circulation. Further, good collateralization may mitigate this hemodynamic impact, partially explaining the protective effect of collateral circulation against recurrent stroke in such patients.

Abstract 175: Cerebral Vasoreactivity is Impaired in Children with Sickle Cell Disease

Background: Sickle cell disease (SCD) is the most common cause of stroke in children. Impairment of vasodilatory capacity reflecting reduced cerebrovascular reserve was previously shown in adults with SCD and might play a role in the pathophysiology of stroke in such patients. We assessed the hypothesis that children with SCD would also have a higher frequency of impaired cerebral vasoreactivity when compared to healthy age-matched subjects. Patients and Methods: Patients were selected from the pediatric outpatient clinic of the Department of Hematology at our University Hospital. All those patients with SCD disease (diagnosis confirmed by hemoglobin electrophoresis on cellulose acetate) without a history of symptomatic stroke aged 10 to 18 years old were evaluated. Healthy children of similar age and gender were also studied. Transcranial Doppler (TCD) was performed in all patients and controls subjects, with breath-holding maneuver and calculation of the breath-holding index (BHI) to assess cerebral vasoreactivity. The BHI was obtained by dividing the percentage increase in mean flow velocity occurring during breath holding by the length of time (seconds) subjects hold their breath after a normal inspiration. BHI was considered abnormal if &lt; 0.69. Results: TCD was performed in 42 patients (mean age 12.7 +/-2.2 years) and 20 controls (mean age 13.90 +/-3.04 years). Blood flow velocities were higher in patients with SCD than in healthy volunteers in all arteries evaluated (p&lt;0.01). Cerebral blood flow velocities were negatively correlated with hemoglobin levels (p&lt;0.05). BHI values in patients with SCD were significantly lower than in control subjects (1.27 +/-0.65 versus 1.74 +/- 0.15, p=0.01 at left and 1.16 +/- 0.45 versus 1.61 +/- 0.11, p&lt;0.01 at right). BHI was abnormal in 19% of the patients and none of the healthy controls (p=0.04). Conclusions: In conclusion, children with SCD may have impaired cerebral vasoreactivity, with low BHI values suggesting a reduced autoregulation capacity in these patients.

Abstract WP152: Collateral Circulation Alters Downstream Hemodynamic Stress Caused by Intracranial Atherosclerotic Stenosis

Background and purpose: Fractional flow reserve (FFR) has exceled the degree of stenosis and become the new guiding post for identifying functionally severe coronary artery lesions. In the current study, we utilized a similar indicator, fractional flow (FF), to gauge the hemodynamic impact of symptomatic intracranial atherosclerotic stenosis (ICAS), and to clarify its relationships with the severity of stenosis and collateral status. Methods: Patients with symptomatic ICAS (70-99% stenosis) confirmed on digital subtraction angiography (DSA) were consecutively recruited. FF was obtained during DSA examination, defined as the ratio of pressures measured distal to an ICAS lesion (Pd) and within the aorta (Pa), by pressure sensors. Leptomeningeal collaterals was grading from zero (absent) to four (complete compensatory) based on DSA examination. The correlations between FF, anatomical stenosis and collateral status were analyzed. Results: Twenty five patients with a mean age of 55.6years were included. The median percentage of stenosis and median FF were 82.3% and 0.68, respectively. Eleven patients were evaluated as poor collaterals (grade 0-2), and fourteen patients were good collaterals (grade 3-4). Overall, the hemodynamic impact of the lesions aggravated (with a decreased FF) as the percentage of stenosis increased (r= -0.398,P =0.06). However, the collateral status significantly altered such correlation, which was more significant in patients with poor collateral circulation (r=-0.677, P=0.032), but did not exist in patients with good collateral circulation (r=-0.279, P=0.356). Conclusions: An anatomically severe (70-99%) symptomatic ICAS lesion may lay significant hemodynamic stress downstream as assessed by the indicator FF. However, a good collateral circulation may mitigate such hemodynamic impact, which may partly explain the protective effect of good collaterals against recurrent stroke in such patients.

Role of closure of patent foramen ovale in cryptogenic stroke: Current status.

Ischaemic stroke is among the leading causes of disability and death. Despite extensive vascular, cardiac and serological evaluations, the cause remains unknown in 20%-40% of patients. These are classified as cryptogenic stroke. Paradoxical embolism is one of the many causes of cryptogenic stroke. The term paradoxical embolism is used to describe an embolus of venous origin entering the systemic circulation through a patent foramen ovale (PFO), atrial septal defect (ASD), ventricular septal defect or extracardiac communication such as pulmonary arteriovenous malformation. PFO is present in about 25% of the population. PFO is seen more commonly in patients with cryptogenic stroke. Secondary prevention of stroke in such patients includes the prevention of formation of a thrombus with antiplatelets, vitamin K antagonists or closure of the PFO by either surgery or the percutaneous route. Percutaneous closure using devices has been shown to be safe and beneficial in preventing secondary stroke. Data from randomized trials have shown device closure to be superior to medical management in the secondary prevention of cryptogenic stroke due to PFO.

Abstract WP249: The “Bucket Test” may Improve Detection of Stroke in Patients With Acute Dizziness

The diagnosis of a stroke in the emergency department (ED) can be difficult when a patient presents primarily with dizziness. Approximately 1/3 of such patients are misdiagnosed with a benign ear condition. While MRI may detect a stroke in such patients, it may not be readily available in many ED. Therefore, there is a need to improve clinical recognition of strokes among acutely dizzy patients. The “bucket test” (BT) involves the use of a bucket that has inside of it a series of images arranged in a straight line that can be aligned with earth’s vertical. In research lab settings, more than 90% of patients with posterior circulation strokes misalign the images off the vertical. However, the utility of a portable version of BT in diagnosing stroke among dizzy patients in ED setting has not been evaluated. We hypothesized that BT can be used by ED physicians as a screening tool for stroke in dizzy patients. We tested a portable version of BT on dizzy patients in ED of a tertiary center. We prospectively enrolled 81 acutely dizzy patients presenting to ED between February 2012 and February 2015. Patients also had brain imaging (CT in 5, MRI in 22). Using MRI/stroke specialist as reference, a total of 7 patients had stroke/TIA. All had clearly abnormal BT and no patient with a stroke/TIA had a normal/equivocal BT (BT sensitivity 100%; 95% CI 59 to 100%). Meanwhile, MRI demonstrated stroke in 5/7 of stroke/TIA patients. One patient with negative initial MRI was diagnosed with AICA stroke later by blinded stroke specialist. And one patient had TIA, with initial negative CT, only to return to ED 12 days later with more dizziness and brain MRI then showed an acute stroke. Therefore, the sensitivity of brain MRI was 83%, consistent with prior literature. In sum, the bucket test is a simple bedside screening test that may improve the diagnosis of stroke in the emergently dizzy patient.

Efficacy of Oral Anticoagulation in Stroke Prevention among Sinus-Rhythm Patients Who Lack Left Atrial Mechanical Contraction after Cryoablation.

The customary recommendation is that oral anticoagulation be withdrawn a few months after cryoablation for atrial fibrillation, independently of left atrial mechanical contraction in patients in sinus rhythm. Recently, a 5-fold increase in stroke has been described in sinus-rhythm patients who lack atrial mechanical contraction. One aim of this study was to evaluate the efficacy of oral anticoagulation in preventing postoperative stroke in such patients. This prospective study divided 154 sinus-rhythm patients into 2 groups, depending on the presence (108 patients) or absence (46 patients) of left atrial mechanical contraction at 6 months after surgery, and monitored them annually for 5 years. Those without left atrial contraction were maintained on acenocumarol. The primary endpoint was the occurrence of ischemic stroke. The median follow-up period was 29 ± 16 months; 4 patients (2.5%), all belonging to the group with preserved atrial contraction, had ischemic stroke; the group of patients without left atrial contraction had no episodes of stroke during follow-up. Logistic binary regression analyses showed no evidence of factors independently predictive of stroke. Among anticoagulated patients in sinus rhythm without left atrial contraction, we found the incidence of stroke to be zero. In a small, nonrandomized group such as this, we cannot discount the element of chance, yet we suggest that maintaining anticoagulation might lower the incidence of stroke in this population.

Early Stroke Risk after Transient Ischemic Attack in Patients without Large-Artery Disease or Atrial Fibrillation

Patients with transient ischemic attack (TIA) without large-artery disease (LAD) or atrial fibrillation (AF) on admission may be at higher risk of stroke than previously thought. The aim of this study was to investigate early stroke risk and its predictors in such patients. We studied 410 TIA patients admitted to our institute within 48 hours of onset. Urgent etiological workup revealed that 210 patients had neither symptomatic LAD nor AF. The outcome measure was the stroke occurrence within 7 days after admission. Stroke occurred within 7 days in 15 patients, 7.1% of patients without LAD or AF and 6.5% of those with LAD or AF, showing no statistical difference between the 2 groups. Twelve of the 15 patients were diagnosed with small-vessel disease as the stroke etiology. In multivariable regression analysis, motor lacunar symptoms (odds ratio [OR], 5.7; 95% confidence interval [CI], 1.4-41.1), high systolic blood pressure on admission of 183 mm Hg or greater (OR, 15.3; 95% CI, 3.8-80.2), and positive diffusion-weighted imaging findings (OR, 6.1; 95% CI, 1.6-28.1) were independent predictors for the stroke occurrence within 7 days in patients without LAD or AF. TIA patients should be cautiously managed, even when neither LAD nor AF are identified by urgent workup. Clinical findings as motor lacunar symptom or high admission blood pressure, besides diffusion-weighted imaging findings, may be helpful to predict early stroke in such patients.

Combining carotid endarterectomy with off-pump coronary artery bypass graft surgery is safe and effective.

Background:We, as neurologists, are frequently consulted to give neurological clearance for surgery in patients who are undergoing coronary artery bypass graft (CABG) surgery and have suffered from stroke or transient ischemic attack (TIA) in past. Similarly clearance is also sought in another group of patients who, though have not suffered from stroke or TIA, but found to have significant carotid stenosis on routine screening prior to surgery. Cardiac surgeons and anesthetists want to know the risk of perioperative stroke in such patients and should carotid endarterectomy (CEA) be done along with CABG. In absence of any clear-cut guideline, neurologists often fail to give any specific recommendation.Aim:To find out safety and efficacy of synchronous CEA in patients undergoing CABG.Design:Retrospective study.Materials and Methods:Out of 3,700 patients who underwent CABG, 150 were found to have severe carotid stenosis of >70%. Out of this, 46 patients with >80% stenosis (three symptomatic and 43 asymptomatic) and one patient with >70% symptomatic carotid stenosis (TIA within last 2 weeks) were taken for simultaneous CEA along with CABG. These three symptomatic carotid patients had suffered from stroke within last 6 months.Results:One patient with asymptomatic near total occlusion of carotid artery suffered from hyperperfusion syndrome. None suffered from ischemic stroke, myocardial infarction (MI), or death during perioperative period.Conclusion:Combining CEA along with CABG is a safe and effective procedure.

143 Carotid Intraplaque Neovascularization is Increased in Patients with Prior Ipsilateral Neck Irradiation - A Contrast Enhanced Ultrasound Study

BackgroundIrradiation of the carotid artery during radiotherapy (RT) for head/neck cancer (HNC) increases intima-media thickness, plaque formation and risk of stroke. However, the effects of RT on plaque composition are...

Increased risk of stroke in young head and neck cancer patients treated with radiotherapy or chemotherapy

Chemo-radiotherapy-induced carotid stenosis and cerebrovascular events in head and neck cancer patients can cause severe disability and death. We aimed to estimate the risk of stroke in such patients over a six-year follow-up period. The study cohort consisted of head and neck cancer patients (n=10,172). Cox proportional hazard model was used to compare the stroke-free survival rate between the patients treated with radiotherapy or chemotherapy, surgery alone, and surgery with adjuvant therapy after adjusting for possible confounding factors. At the end of follow-up, 384 patients had strokes: 126 (4.3%) from the surgery alone group, 167 (3.8%) from the radiotherapy or chemotherapy group, and 91 (3.2%) from the surgery with adjuvant therapy (P=0.222). Head and neck cancer patients aged less than 55 years treated with radiotherapy or chemotherapy conferred a 1.8-fold higher risk for stroke (95% CI, 1.22-2.56; P=0.003) after adjusting for patient characteristics, co-morbidities, geographic region, urbanization level, and socio-economic status. There was no statistical difference in stroke risk between different treatment modalities in head and neck cancer patients aged 55 years and more. Young head and neck cancer patients treated with radiotherapy or chemotherapy have higher risks for stroke. Different treatment strategies should be considered in such patients.

Incidence and Management of Ischemic Stroke and Intracerebral Hemorrhage in Patients on Dabigatran Etexilate Treatment

Dabigatran etexilate is an oral, reversible direct thrombin inhibitor and has been recently approved for the prevention of stroke in patients with non-valvular atrial fibrillation. This review describes the incidence and management of stroke and related complications in patients on dabigatran etexilate. Dabigatran is a rapidly acting, and highly selective and reversible inhibitor of thrombin. It also has a potent inhibitory effect on thrombin-induced platelet aggregation, making it effective in preventing both venous and arterial thrombosis. The activated partial thromboplastin time, ecarin clotting time and thrombin time are sensitive tests to evaluate the anticoagulant effects of dabigatran. The rate of ischemic stroke is significantly lower in patients on 150 mg of dabigatran etexilate as compared to 110-mg dose or warfarin (9.2, 13.4, 12 per 1,000 patients, respectively). As there is no standard coagulation test for dabigatran; treatment of acute stroke in such patients is debatable. Careful clinical consideration is required before administering thrombolytic therapy in this patient population. The rate of hemorrhagic stroke was 1.2 and 1.0 per 1,000 patients treated on 110 and 150 mg of dabigatran, respectively. As there is no specific antidote, the only treatment option is discontinuation of the drug and supportive management. Other treatment options, though not clinically proven, include specific reversal agents, which can be individualized according to the severity of the hemorrhage. Dabigatran should be discontinued before invasive procedures depending on the degree of renal impairment and risk of bleeding.

Transcatheter left atrial appendage exclusion, gold or fool's gold?

Non-valvular atrial fibrillation (AF) related stroke primarily originates as embolic event from a left atrial appendage (LAA) thrombus. Oral anticoagulants effectively reduce stroke risk among AF patients. Cardiac operations are frequently coupled with surgical closure of the LAA as a measure to prevent stroke in such patients. Transcatheter LAA exclusion was first introduced in 2001, yet faced difficulties which led to the withdrawal of the initial device line. Recently, several events have revived the interest in this catheter-based technology as a safe and effective alternative to oral anticoagulants among AF patients. This review discusses the role of the LAA in health and disease and gives detailed insight into different transcatheter devices for LAA exclusion with the available clinical evidence.