Stroke Syndrome Research Articles

Neurologic Events Following Pediatric Heart Transplantation

PurposeThe last decade has seen a considerable rise in ventricular assist device (VAD) support as bridge to heart transplant (HT) coupled with increasing transplantation for single ventricle congenital heart disease (SV CHD). Neurologic events (NE) are common in both patient groups. We sought to describe NE before and after HT in the modern era among children and young adults.MethodsWe performed a single center retrospective review of patients who underwent HT between 1/2013 and 4/2020. NE included seizures, stroke, subdural hemorrhage (SDH) and posterior reversible encephalopathy syndrome (PRES). Clinical characteristics were compared between patients with and without post-HT NE.ResultsOverall 163 patients met study criteria, of whom 54 (33%) had a pre-HT NE and 29 (18%) had at least one post-HT NE. Post-HT NE included seizures in 23/163 (14%), strokes in 10/163 (6%), SDH in 9/163 (6%), and PRES in 7/163 (4%). Median time from HT to first post-HT NE was 24 days (IQR 3, 277). Post-HT NE were associated with SDH (6/29 (21%) vs 9/134 (7%), p=0.03), pre-HT ICU admission (11/29 (38%) vs 21/134 (16%), p=0.009), and allograft ischemic time (250 min (IQR 221, 224) vs 223 min (IQR 189, 250), p=0.001), and not with pre-HT NE, SV CHD, or VAD support. ICU admission was an independent predictor of post-HT NE on multivariate analysis (hazard ratio 2.87 (CI 1.09, 7.62), p=0.03). Post-HT NE were associated with significantly decreased survival.ConclusionPost-HT NE are common in children and young adults and occur early post-HT. They are associated with ICU status at time of HT, and not with SV CHD or pre-HT VAD support. Post-HT neurologic events portend a poor prognosis, with 50% mortality by 5 years. The last decade has seen a considerable rise in ventricular assist device (VAD) support as bridge to heart transplant (HT) coupled with increasing transplantation for single ventricle congenital heart disease (SV CHD). Neurologic events (NE) are common in both patient groups. We sought to describe NE before and after HT in the modern era among children and young adults. We performed a single center retrospective review of patients who underwent HT between 1/2013 and 4/2020. NE included seizures, stroke, subdural hemorrhage (SDH) and posterior reversible encephalopathy syndrome (PRES). Clinical characteristics were compared between patients with and without post-HT NE. Overall 163 patients met study criteria, of whom 54 (33%) had a pre-HT NE and 29 (18%) had at least one post-HT NE. Post-HT NE included seizures in 23/163 (14%), strokes in 10/163 (6%), SDH in 9/163 (6%), and PRES in 7/163 (4%). Median time from HT to first post-HT NE was 24 days (IQR 3, 277). Post-HT NE were associated with SDH (6/29 (21%) vs 9/134 (7%), p=0.03), pre-HT ICU admission (11/29 (38%) vs 21/134 (16%), p=0.009), and allograft ischemic time (250 min (IQR 221, 224) vs 223 min (IQR 189, 250), p=0.001), and not with pre-HT NE, SV CHD, or VAD support. ICU admission was an independent predictor of post-HT NE on multivariate analysis (hazard ratio 2.87 (CI 1.09, 7.62), p=0.03). Post-HT NE were associated with significantly decreased survival. Post-HT NE are common in children and young adults and occur early post-HT. They are associated with ICU status at time of HT, and not with SV CHD or pre-HT VAD support. Post-HT neurologic events portend a poor prognosis, with 50% mortality by 5 years.

Bushen Tiaodu Yizhi acupuncture combined with computer-assisted cognitive training for post stroke cognitive impairment: a randomized controlled trial

To explore the effect of Bushen Tiaodu Yizhi acupuncture combined with computer-assisted cognitive training on the recovery of cognitive function and activities of daily living in patients with post stroke cognitive impairment. A total of 98 patients with post stroke cognitive impairment were randomized into an observation group (50 cases, 6 cases dropped off) and a control group (48 cases, 5 cases dropped off). Both groups were treated with conventional treatment, such as computer-assisted cognitive training. On the basis of the conventional treatment, Bushen Tiaodu Yizhi acupuncture at Taixi (KI 3), Sanyinjiao (SP 6), Shuigou (GV 26), Baihui (GV 20), ect. was given in the observation group. In the control group, acupuncture at acupoints of limbs was given. The treatment was given once a day, 5 times a week for 8 weeks. Before and after treatment, the scores of Montreal cognitive assessment (MoCA) scale, modified Barthel index (MBI) and stroke syndrome of TCM scale were used to evaluate the cognitive function, activities of daily living and syndrome of TCM in the two groups. The latency and amplitude of P300 were detected by electromyographs and evoked response instrument. And the clinical efficacy was evaluated in the two groups. Compared before treatment, the MoCA and MBI scores were increased (P<0.01), and the scores of stroke syndrome of TCM scale were decreased (P<0.01) after treatment in the two groups. After treatment，the MoCA and MBI scores in the observation group were higher than the control group (P<0.01, P<0.05), and the score of stroke syndrome of TCM scale was lower than the control group (P<0.05). Compared before treatment, the latency of P300 was shortened and amplitude was prolonged after treatment in the two groups (P<0.01). After treatment, in the observation group, the latency of P300 was shorter, and amplitude was longer than the control group (P<0.01). The effective rate was 86.4% (38/44) in the observation group, which was higher than 67.4% (29/43) in the control group (P<0.01). Bushen Tiaodu Yizhi acupuncture combined with computer-assisted cognitive training could improve the cognitive function of patients with post stroke cognitive impairment.

Shifting of global aphasia to Wernicke\u2019s aphasia in a patient with intact motor function: a case report

BackgroundGlobal aphasia without hemiparesis (GAWH) is a rare stroke syndrome characterized by the dissociation of motor and language functions. Here, we present a case of GAWH with the patient later regaining speech fluency.Case presentationA 73-year-old man was admitted to our emergency department immediately after an episode of syncope. On arrival, we noted his global aphasia but without any focal neurologic signs. Computed tomography (CT) perfusion scans showed a large hypodense region over his left perisylvian area. Under the impression of acute ischaemic stroke, he received recombinant tissue plasminogen activator (rtPA) injection and was treated as an inpatient. The patient was later discharged with GAWH status and received regular speech rehabilitation. After 14 months of rehabilitation, the patient gradually recovered his language expression ability. The degree of aphasia was evaluated with the Concise Chinese Aphasia Test (CCAT), and we obtained brain single photon emission computed tomography (SPECT) scans to assess cerebral blood flow.ConclusionA patient with severe impairments of Broca’s and Wernicke’s areas was able to talk fluently despite being unintelligible. SPECT revealed relative high level of radioactivity uptake in the right frontal lobe, suggesting the deficits in speech fluency could have been compensated by the right hemisphere. Although this is a single case demonstration, the results may strengthen the role of the right hemisphere in GAWH patients and suggests additional study that examines the possible benefits of stimulating activity at right homologous regions for recovering language function after global aphasia.

Lacunar Stroke Lesion Extent and Location and White Matter Hyperintensities Evolution 1 Year Post-lacunar Stroke.

Lacunar strokes are a common type of ischemic stroke. They are associated with long-term disability, but the factors affecting the dynamic of the infarcted lesion and the brain imaging features associated with them, reflective of small vessel disease (SVD) severity, are still largely unknown. We investigated whether the distribution, volume and 1-year evolution of white matter hyperintensities (WMH), one of these SVD features, relate to the extent and location of these infarcts, accounting for vascular risk factors. We used imaging and clinical data from all patients [n = 118, mean age 64.9 (SD 11.75) years old] who presented to a regional hospital with a lacunar stroke syndrome within the years 2010 and 2013 and consented to participate in a study of stroke mechanisms. All patients had a brain MRI scan at presentation, and 88 had another scan 12 months after. Acute lesions (i.e., recent small subcortical infarcts, RSSI) were identified in 79 patients and lacunes in 77. Number of lacunes was associated with baseline WMH volume (B = 0.370, SE = 0.0939, P = 0.000174). RSSI volume was not associated with baseline WMH volume (B = 3.250, SE = 2.117, P = 0.129), but predicted WMH volume change (B = 2.944, SE = 0.913, P = 0.00184). RSSI location was associated with the spatial distribution of WMH and the pattern of 1-year WMH evolution. Patients with the RSSI in the centrum semiovale (n = 33) had significantly higher baseline volumes of WMH, recent and old infarcts, than patients with the RSSI located elsewhere [median 33.69, IQR (14.37 50.87) ml, 0.001 ≤ P ≤ 0.044]. But patients with the RSSI in the internal/external capsule/lentiform nucleus experienced higher increase of WMH volume after a year [n = 21, median (IQR) from 18 (11.70 31.54) ml to 27.41 (15.84 40.45) ml]. Voxel-wise analyses of WMH distribution in patients grouped per RSSI location revealed group differences increased in the presence of vascular risk factors, especially hypertension and recent or current smoking habit. In our sample of patients presenting to the clinic with lacunar strokes, lacunar strokes extent influenced WMH volume fate; and RSSI location and WMH spatial distribution and dynamics were intertwined, with differential patterns emerging in the presence of vascular risk factors. These results, if confirmed in wider samples, open potential avenues in stroke rehabilitation to be explored further.

Pre-hospital triage of suspected acute stroke patients in a mobile stroke unit in the rural Alberta

Mobile Stroke Unit (MSU) expedites the delivery of intravenous thrombolysis in acute stroke patients. We further evaluated the functional outcome of patients shipped to a tertiary care centre or repatriated to local hospitals after triage by MSU in acute stroke syndrome in rural northern Alberta. Consecutive patients with suspected acute stroke syndrome were included. On the basis of neurology consultation and, Computed Tomography findings, patients, who were thrombolysed or needed advanced care were transported to the Comprehensive stroke center (CSC) (Triage to CSC group). Other patients were repatriated to local hospital care (Triage to LHC group). A total of 156 patients were assessed in MSU, 73 (46.8%) were female and the mean age was 66.6 ± 15 years. One hundred and eight (69.2%) patients, including 41 (26.3%) treated with thrombolysis were transported to the CSC (Triage to CSC group) and 48 (30.8%) were repatriated to local hospital care. The diagnosis made in MSU and final diagnosis were matching in 88% (95) and 91.7% (44, p = 0.39) in Triage to CSC and Triage to LHC groups respectively. Prehospital triage by MSU of acute stroke syndrome can reliably repatriate patients to the home hospital. The proposed model has the potential to triage patients according to their medical needs by enabling treatment in home hospitals whenever reasonable.

Acute ischemic stroke due to posterior cerebral artery P2 segment occlusion treated with mechanical thrombectomy

Abstract Introduction: Mechanical thrombectomy (MT) has become part of the standard treatment for patients who have acute ischemic stroke due to large-vessel occlusion in the anterior cerebral circulation. But the safety and effectiveness of MT for posterior cerebral artery (PCA) is still controversial. Patient concerns: We report a 40-year-old man with a medical history of hypertension who was non-compliant with the treatment. He presented to the hospital with right extremity paralysis, aphasia, and left gaze paralysis due to the occlusion of left PCA P2 segment (National Institutes of Health Stroke Scale Score 16). Head computed tomography showed infarction area of left temporal lobe and occipital lobe. Diagnosis: A head computed tomography angiography examination showed left PCA P2 segment occlusion. Interventions: The patient underwent MT and subsequent angiography showed left PCA P2 segment occlusion was recanalized after MT. Outcomes: The patient's symptoms improved completely after MT. Conclusion: The clinical symptoms due to PCA P2 segment occlusion may be mistaken clinically for MCA stroke syndrome, which may lead to severe functional deficit. MT seems to be safe and effective in treating PCA P2 segment occlusion.

Truncal pulsion in acute ischemic stroke – Clinico-anatomical correlation

Context: Truncal pulsion is a compelling sensation of being pulled to one side, in the context of normal motor and sensory functions and normal co-ordination. It is seen in a variety of ischemic strokes.&#x0D; Aims: This article aims at identifying ischemic stroke syndromes associated with truncal pulsion, with review of the neural substrate responsible, to help in recognition and reporting.&#x0D; Settings and Design: This was a prospective study conducted at Department of Neurology, at Pushpagiri institute of medical sciences and research centre, Thiruvalla, Kerala, India, over a period of 5 years, among patients with acute ischemic stroke.&#x0D; Methods and Material: We studied all patients with acute ischemic stroke, who were admitted to our department, over a five-year period. Patients presenting with truncal pulsion were shortlisted and were assessed by investigators independently. All patients underwent MRI brain, which was assessed by investigators 1 and 2, independently. The demographic profile, risk factors, clinical features, neuroimaging findings and outcomes were analysed using SPSSv21.&#x0D; Results: A total of 1456 patients with acute ischemic strokes were identified, of which 27 with truncal pulsion were included in the study. The common sites of infarction resulting in truncal pulsion were lateral medulla, cerebellum, thalamus, pons and midbrain. One patient had infarct involving anterior cingulate. Truncal pulsion was ipsilateral in infarcts involving medulla and cerebellum and contralateral in infarcts involving the pons, midbrain, mesencephalo-diencephalic junction, thalamus and cingulate.&#x0D; Conclusions: Truncal pulsion, a compelling sensation of falling, is a disabling symptom occurring in a variety of strokes and it poses significant challenge in neuro-rehabilitation.&#x0D;

Study of Metabolic Syndrome in Acute Stroke

Study of Metabolic Syndrome in Acute Stroke

Intravenous thrombolysis in stroke with admission NIHSS score 0 or 1.

Up to 30% of stroke patients initially presenting with non-disabling or mild deficits may experience poor functional outcome. Despite, intravenous thrombolysis remains controversial in this subgroup of stroke patients due to its uncertain risk benefit ratio. We aimed to analyze the real-world experience with intravenous thrombolysis in stroke patients presenting with very low NIHSS. Data of stroke patients presenting with mild initial stroke severity (NIHSS 0-5) including vascular risk factors, stroke syndrome and etiology, early neurological deterioration, symptomatic intracerebral haemorrhage (sICH), and functional outcome by modified Rankin Scale were extracted from a large nationwide stroke registry and analysed. Patients were categorized and compared according to admission severity NIHSS 0-1 versus NIHSS 2-5 and intravenous thrombolysis use. Seven hundred and three (2%) of 35,113 patients presenting with NIHSS 0-1 and 6316 (13.9%) of 45,521 of patients presenting with NIHSS 2-5 underwent intravenous thrombolysis. In the NIHSS 0-1 group, intravenous thrombolysis was associated with early neurological deterioration (adjusted OR 8.84, CI 6.61-11.83), sICH (adjusted OR 9.32, CI 4.53-19.15) and lower rate of excellent outcome (mRS 0-1) at three months (adjusted OR 0.67, CI 0.5-0.9). In stroke patients with NIHSS 2-5, intravenous thrombolysis was associated with early neurological deterioration (adjusted OR 1.7, 1.47-1.98), sICH (adjusted OR 5.75, CI 4.45-7.45), and higher rate of excellent outcome (mRS 0-1) at three months (adjusted OR 1.21, CI 1.08-1.34). Among patients with NIHSS 0-1, intravenous thrombolysis did not increase the likelihood of excellent outcome. Moreover, potential signals of harm were observed. Further research seems to be warranted.

Lambl’s filaments as a cause for cardiogenic embolism of cerebral vessels and coronary arteries

The article presents a specific clinical case and literature data on a rare finding in the heart cavity — Lambl’s fila ments. Histologically, these are cells of fibroelastic tissue covered with stroma and epithelial layer. They do not have a vascular sheath, so they are devoid of granulation tissue. Lambl’s growths occur on both their own and prosthetic heart valves. Very rarely, threads can also be seen in areas other than heart valves such as the papillae, atria, and chords. These lesions can be seen on the echocardiogram accidentally or in connection with serious complications such as embolic stroke or acute coronary syndrome after their separation and distribution to distant organs. Lambl’s growths occur in adults and children, but the prevalence is higher in the former and increases with age. On the echocardiogram, the incidence reaches a peak between the ages of 61 and 70, and then decreases due to the aging of heart valves, which are increasingly calcified. The disease is more common in men than in women.

Cardioembolic stroke in syndrome of noncompaction cardiomyopathy

Stroke remains one of the most common diseases and causes of death. Reducing mortality from stroke is in great dependence on the effectiveness of its prevention, which, in turn, is impossible without an accurate understanding of its causes and mechanisms of development. The article represents the history of a patient with ischemic cardioembolic stroke that developed against noncompaction cardiomyopathy, a relatively rare disease that can be diagnosed with the use of available modern research methods. The algorithm for examining a patient with suspected cardioembolic stroke includes long-term Holter monitoring, echocardiography, CT and MRI of the heart, which makes it possible to identify rare causes of cardiac thromboembolism. Postexposure prophylaxis of stroke in such cases is likely to include the use of anticoagulants, but studies aimed to clarify most effective methods of recurrent strokes prevention in rare causes of cardiac thromboembolism are still being conducted.

Persistent decline of hospitalizations for acute stroke and acute coronary syndrome during the second wave of the COVID-19 pandemic in Greece: collateral damage unaffected.

Background:An alarming cerebro/cardiovascular collateral damage, reflected by a decline in admissions for acute stroke (AS) and acute coronary syndrome (ACS), was observed during the initial phase of the COVID-19 pandemic, thereby leading to a re-design of public campaigns. However, there are limited data regarding the AS and ACS hospitalization rates during the second wave of the pandemic, which was followed by re-imposition of lockdowns.Methods:We calculated the rate of AS and ACS hospitalizations from three representative tertiary care hospitals in Greece during a 2-month period (November–December 2020) of the second wave of the COVID-19 pandemic compared with the corresponding control period in 2019 from three representative tertiary care hospitals in Greece. This was a follow-up study with identical design to our previous report evaluating AS and ACS hospitalizations during the first wave of the pandemic (March–April 2020).Results:Compared with 2019, there was a 34% relative reduction of AS hospitalizations [incidence rate ratio (IRR): 0.66, 95% confidence interval (CI): 0.48–0.92, p = 0.013] and 33% relative reduction of ACS hospitalizations (IRR: 0.67, 95% CI: 0.54–0.83, p < 0.001) during the second wave of the COVID-19 pandemic. The relative reduction was smaller and did not reach the level of statistical significance for the respective syndromes (haemorrhagic stroke: IRR 0.87, 95% CI: 0.41–1.82, p = 0.71; ST-elevation myocardial infarction: IRR 0.81, 95% CI: 0.57–1.14, p = 0.22).Conclusion:AS and ACS hospitalizations were persistently reduced during the second wave of the COVID-19 pandemic compared with 2019 in Greece. This decline was similar to the observations during the first wave despite the large differences in the epidemiological COVID-19 burden. Lockdowns, a common characteristic in both waves, appear to have a detrimental indirect impact on cerebro/cardiovascular diseases in the general population.

Arterial Disease Computational Prediction and Health Record Feature Ranking Among Patients Diagnosed With Inflammatory Bowel Disease

Inflammatory bowel diseases (IBDs) are a group of disorders causing chronic inflammation of small intestine and colon, and include Chron's disease and ulcerative colitis as most common occurrences. Patients suffering from IBD have more chances to experience an arterial event, such as a stroke or an acute coronary syndrome. In this setting, computational data mining methods applied to electronic medical records of patients diagnosed with IBD can provide useful information regarding the possibility for them to develop arterial diseases, in few minutes and at small cost. In this manuscript, we analyzed a dataset of 90 patients diagnosed with IBD, 30 of which having an arterial disease. After detecting the capability of predicting the arterial event and the most important features of the whole dataset, we repeated the analysis only on the subset of 30 patients suffering from both IBD and arterial disease. Our results show that machine learning can precisely predict both the occurrence of an arterial event and its type (stroke or acute coronary syndrome) from medical records, and can provide useful rankings about the most important clinical variables available in the dataset. Our otherwise unobservable findings can have a strong impact in the clinical settings, allowing physicians and medical doctors to make better decisions regarding prognoses and therapies of patients suffering from this disease.

SARS-CoV-2: Pathogenic Mechanisms and Host Immune Response.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an enveloped, positive-sense RNA coronavirus responsible for the COVID-19 pandemic. Since December 2019, coronavirus disease 2019 (COVID-19) has affected more than 127 million people, 2.7 million deaths globally (as per WHO dashboard, dated 31 March, 2020), the virus is capable of transmitting from human to human via inhalation of infected respiratory droplets or aerosols or contact with infected fomites. Clinically, patients with COVID-19 present with severe respiratory distress syndrome, which is very similar to the presentation of other respiratory viral infections. A huge variation in the host response exists, with the resulting symptoms varying from mild to moderate. Comorbidities such as cardiovascular disease, hypertension, diabetes, coagulation dysfunction, stroke, malignant tumor and multiple organ dysfunction syndrome, as well as age and sex, are associated with severe COVID-19 cases. So far, no targeted therapies have been developed to treat this disease and existing drugs are being investigated for repurposing. This chapter discusses the epidemiology, clinical features of COVID-19, pathogenesis and the innate and adaptive immune response mounted by the host to the SARS-CoV-2 infection. A deeper understanding of the host-pathogen interaction is fundamental to the development of a vaccine.

Ischemic Stroke Due to Paradoxical Embolism in a Patient with Patent Foramen Ovale, Bilateral Distal Deep Vein Thrombosis and Platypnea-Orthodeoxia Syndrome: A Case Report

Patent foramen ovale (PFO) is a common congenital cardiac defect. It is usually asymptomatic, but it can be associated with relevant clinical manifestations such as cryptogenic stroke and platypnea-orthodeoxia syndrome. We present the case of a patient with hemodynamically significant carotid artery stenosis who underwent endarterectomy for a transient ischemic attack (TIA). After surgery, the patient presented an ischemic stroke due to M2 occlusion treated with mechanical thrombectomy. During hospitalization, a distal bilateral deep vein thrombosis was found. The patient developed respiratory failure due to a massive right-to-left shunt through a large PFO (platypnea-orthodeoxia syndrome). These findings are consistent with the hypothesis that the TIA and the subsequential ischemic stroke were related to paradoxical embolism rather than atherothromboembolism. The aim of our case report is to raise awareness of the possible complications of such a common finding as PFO.

Prevalence of syphilis reactivity in patients with stroke, cognitive impairment and extrapyramidal syndromes: a retrospective study.

In the last two decades, there has been a resurgence of syphilis worldwide. However, epidemiological data on neurosyphilis are inconsistent for the lack of reporting data and diagnostic gold standard tests. The aim of the present study was to estimate the prevalence of syphilis reactivity in a cohort of patients with neurological diseases of our hospital. We retrospectively analyzed the medical records of the patients hospitalized at the Stroke Unit of the Neurology Clinic and those suffering from cognitive impairment hospitalized at the acute ward of the Geriatrics Clinic between January 2017 and December 2019. Also the patients who attended the Movement disorder outpatient clinic during the same study period were examined. To detect syphilis reactivity a qualitative specific treponemal test on patient’s serum was performed: the Treponema pallidum haemagglutination assay (TPHA). A total of 652 patients were admitted and 315 of them (52%) were submitted to a routine screening for syphilis: 307 (97%) were negative while 8 (3%) had a positive syphilis serology. The TPHA-positive patients (4 males, 4 females) were 2 patients with stroke, 5 with cognitive impairment and 1 with Parkinsonism with a mean age of 83 years, suffering from multiple comorbidities. Although the patients we have retrospectively studied have not undergone lumbar puncture to confirm the diagnosis of neurosyphilis, the not negligible syphilis reactivity rate found in our series suggests that serological screening for syphilis should be reviewed as a routine screening test in neurology and geriatrics departments, especially if the clinical presentation of the neurological diseases is atypical.

Cardio-Cerebral Infarction Syndrome (CCIS): Definition, Diagnosis, Pathophysiology and Treatment

Acute ischemic stroke (AIS) and coronary artery disease are the major causes of death in Palestine and in the world. Ischemic stroke and acute coronary syndrome have similar vascular risk factors and may evolve as a complication of the respective other disease. The prevalence of coronary artery disease has been reported in one fifth of stroke patients. high incidence rate of acute myocardial infarction (AMI) after recent ischemic stroke and the high risk of acute ischemic stroke after recent myocardial infarction has been reported in several clinical or observational studies. Patients are at increased risk of ischemic stroke following recent myocardial infarction, and aggressive treatment of AMI, including use of reperfusion therapy, decreases the risk of AIS. For patients presenting with AIS in the setting of a recent MI, treatment with alteplase, an intravenous tissue plasminogen activator, can be given, but may be harmful in many conditions. It is important for clinicians to recognize that troponin elevations can occur in the setting of AIS as well as other clinical scenarios and that this may have implications for short- and long-term mortality. So that acute or recent problem in the heart or brain that could result in an acute infarction of the other. In this review we describe the definition and new classification of the cardio-cerebral infarction syndrome with 3 subtypes that reflect the definition, pathophysiology and treatment options.

Essential Role of the Mitochondrial Na &lt;sup&gt;+&lt;/sup&gt;/Ca &lt;sup&gt;2+&lt;/sup&gt; Exchanger - NCLX in Mediating the PDE2 Dependent Neuronal Survival and Learning

Consumption of coffee and caffeine enhances learning efficiency and reduces the risk of stroke and neurodegenerative syndromes by a molecular pathway that is poorly understood. Here we fluorescently monitored mitochondrial Ca2+ transients in hippocampal neurons evoked by caffeine. Surprisingly, caffeine also had a long-lasting potentiation effect on mitochondrial Ca2+ ([Ca2+]m) efflux evoked by depolarization, in WT but not in neurons deficient in the mitochondrial Na+/Ca2+ exchanger NCLX. We reasoned that the caffeine effect is linked to phosphodiesterase inhibition, and focused on PDE2 that has the highest affinity to caffeine and is targeted to the mitochondria. Pretreatment of neurons with the selective PDE2 inhibitor Bay 60-7550 mimicked caffeine and rescued [Ca2+]m efflux triggered by neuronal depolarization. PDE2 inhibition also enhanced [Ca2+]m efflux triggered by neuromodulators. Inhibition of PDE2 acted by increasing mitochondrial cAMP thereby promoting NCLX phosphorylation. We found that protection of neurons against excitotoxic insults, conferred by PDE2 inhibition was diminished in NCLX KO neurons, thus is NCLX dependent. Finally, administration of Bay 60-7550 enhanced new object recognition learning in WT but not in NCLX KO mice. Our results identify a pathway linking caffeine and PDE to [Ca2+]m signaling, thereby providing new therapeutic targets for treating cognitive impairment and excitotoxicity.

Greater decline of acute stroke admissions compared with acute coronary syndromes during COVID‐19 outbreak in Greece: Cerebro/cardiovascular implications amidst a second wave surge

A remarkable decline in admissions for acute stroke and acute coronary syndrome (ACS) has been reported in countries severely hit by the COVID-19 pandemic. However, limited data are available from countries with less COVID-19 burden focusing on concurrent stroke and ACS hospitalisation rates from the same population. The study was conducted in three geographically and demographically representative COVID-19 referral university hospitals in Greece. We recorded the rate of stroke and ACS hospital admissions during a 6-week period of the COVID-19 outbreak in 2020 and compared them with the rates of the corresponding period in 2019. We found a greater relative reduction of stroke admissions (51% [35 vs. 71]; incidence rate ratio [IRR]: 0.49, p=0.001) compared with ACS admissions (27% [123 vs. 168]; IRR: 0.73, p=0.009) during the COVID-19 outbreak (p=0.097). Fewer older (>65years) patients (stroke: 34.3% vs. 45.1%, odds ratio [OR]: 0.64, p=0.291; ACS: 39.8% vs. 54.2%, OR: 0.56, p=0.016) were admitted during the COVID-19 compared with the control period. Hospitalisation rates both for stroke and ACS were reduced during the COVID-19 outbreak in a country with strict social distancing measures, low COVID-19 incidence and low population mortality. Lack of triggers for stroke and ACS during social distancing/quarantining may explain these observations. However, medical care avoidance attitudes among cerebro/cardiovascular patients should be dissipated amidst the rising second COVID-19 wave.

Dysregulation of the orexin/hypocretin system is not limited to narcolepsy but has far-reaching implications for neurological disorders.

Neuropeptides orexin A and B (OX-A/B, also called hypocretin 1 and 2) are released selectively by a population of neurons which projects widely into the entire central nervous system but is localized in a restricted area of the tuberal region of the hypothalamus, caudal to the paraventricular nucleus. The OX system prominently targets brain structures involved in the regulation of wake-sleep state switching, and also orchestrates multiple physiological functions. The degeneration and dysregulation of the OX system promotes narcoleptic phenotypes both in humans and animals. Hence, this review begins with the already proven involvement of OX in narcolepsy, but it mainly discusses the new pre-clinical and clinical insights of the role of OX in three major neurological disorders characterized by sleep impairment which have been recently associated with OX dysfunction, such as Alzheimer's disease, stroke and Prader Willi syndrome, and have been emerged over the past 10years to be strongly associated with the OX dysfunction and should be more considered in the future. In the light of the impairment of the OX system in these neurological disorders, it is conceivable to speculate that the integrity of the OX system is necessary for a healthy functioning body.