Symptomatic Cerebral Infarction Research Articles

White matter integrity and functional connectivity of the default mode network in acute stroke are associated with cognitive outcome three months post-stroke

BackgroundKnowledge about factors that are associated with post-stroke cognitive outcome is important to identify patients with high risk for impairment. We therefore investigated the associations of white matter integrity and functional connectivity (FC) within the brain's default-mode network (DMN) in acute stroke patients with cognitive outcome three months post-stroke. MethodsPatients aged between 18 and 85 years with an acute symptomatic MRI-proven unilateral ischemic middle cerebral artery infarction, who had received reperfusion therapy, were invited to participate in this longitudinal study. All patients underwent brain MRI within 24–72 h after symptom onset, and participated in a neuropsychological assessment three months post-stroke. We performed hierarchical regression analyses to explore the incremental value of baseline white matter integrity and FC beyond demographic, clinical, and macrostructural information for cognitive outcome. ResultsThe study cohort comprised 34 patients (mean age: 64 ± 12 years, 35% female). The initial median National Institutes of Health Stroke Scale (NIHSS) score was 10, and significantly improved three months post-stroke to a median NIHSS = 1 (p < .001). Nonetheless, 50% of patients showed cognitive impairment three months post-stroke. FC of the non-lesioned anterior cingulate cortex of the affected hemisphere explained 15% of incremental variance for processing speed (p = .007), and fractional anisotropy of the non-lesioned cingulum of the affected hemisphere explained 13% of incremental variance for cognitive flexibility (p = .033). ConclusionsWhite matter integrity and functional MRI markers of the DMN in acute stroke explain incremental variance for post-stroke cognitive outcome beyond demographic, clinical, and macrostructural information.

A High Immediate Postoperative Systemic Immune-inflammation Index Is Associated With Postoperative Symptomatic Cerebral Infarction in Moyamoya Patients Undergoing Combined Revascularization Surgery

Background: Inflammation plays a role in the pathogenesis of cerebral infarction. Postoperative symptomatic cerebral infarction (SCI) is a complication after revascularization surgery in patients with moyamoya disease (MMD). We investigated the association between the systemic-immune-inflammation index (SII) and postoperative SCI during hospital stay in such patients. Methods: Perioperative data were retrospectively obtained from 681 MMD patients who underwent revascularization surgery. SII cutoff values were identified as those where the sum of sensitivity and specificity associated with SCI were highest. Patients were divided into 4 subgroups according to the preoperative and immediate postoperative cutoff SII: HH (preoperative and postoperative SII high, n=22), LH (low preoperative and high postoperative SII, n=68), HL (high preoperative and low postoperative SII, n=125), and LL (preoperative and postoperative SII low, n=466). Results: Postoperative SCI occurred in 54 (7.6%) patients. The cutoff values for preoperative and immediate postoperative SII were 641.3 and 1925.4, respectively. Postoperative SCI during hospital stay was more frequent in the high postoperative SII group than in the low postoperative SII group (25.6% vs. 4.9%; P&lt;0.001). Multivariate analysis revealed that a high immediate postoperative SII was a predictor of postoperative SCI (odds ratio, 11.61; 95% CI: 5.20-26.00; P&lt;0.001). Postoperative SCI was lower in group LL than in group LH (3.6% vs. 23.5%, P&lt;0.008) and was lower in group HL than in groups HH and LH (9.6% vs. 31.8% and 23.5%, both P&lt;0.05). Conclusions: A high immediate postoperative SII was associated with postoperative SCI during hospital stay in MMD patients who underwent revascularization surgery.

Prevalence of symptomatic acute cerebral infarction among patients with COVID-19 and D-dimer as a predictor of cerebral infarction

Objectives: This study sought to investigate the frequency of symptomatic acute cerebral infarction (sACI) among patients with novel coronavirus (COVID-19) disease and the predictive value of laboratory parameters such as D-dimer and neutrophil-to-lymphocyte ratio (NLR) in sACI. Methods: This retrospective case-control study analyzed the data of 2,378 patients with COVID-19 registered in our database between April 1, 2020 and November 30, 2020. Of these patients, a total of 119 subjects were included in the study, including 31 COVID-19 patients with sACI (patient group) and 88 randomly selected COVID-19 patients without sACI (control group). Categorical variables were compared using Chi-square test and predictive value of the variables was analyzed using receiver operating characteristics (ROC) curve analysis. Results: Thirty one (1.30%) of 2,378 COVID-19 patients had sACI. Mann-Whitney U test showed that median D-dimer, neutrophil and NLR values were significantly higher in the sACI group compared to the control group (p = 0.004, p &lt; 0.048 and p = 0.007, respectively). ROC analysis yielded the following areas under the ROC curve: D-dimer = 0.674 (95% CI, 0.569-0.779), NLR = 0.663 (95% CI, 0.559-0.767) and neutrophils = 0.620 (95% CI, 0.509-0.73). Conclusion: The results of the present study showed that elevated D-dimer levels can be used as a predictor of sACI in COVID-19 patients.

Custom shaping of distal access catheter for navigation of microcatheter into inferolateral and meningohypophyseal trunk feeders.

Navigating a microcatheter to tiny feeding arteries such as the inferolateral trunk (ILT) and meningohypophyseal trunk (MHT) of the internal carotid artery (ICA) is technically challenging because of the anatomical features of steep angulation, small diameter, and significant caliber difference from the ICA. To guide the microcatheter to these ICA side branch feeders, the authors thought that a custom shaping of the intermediate catheter would be helpful to determine the direction of the microcatheter and strongly back it up. The aim of this study was to report the detailed methodology and clinical outcomes of patients who had undergone the embolization of ILT and MHT feeders using this method. This was a retrospective study of consecutive patients with intracranial tumors and dural arteriovenous fistulas (DAVFs) who had undergone endovascular embolization. The details of the embolization procedures were examined, especially the technique of guiding a low-profile microcatheter supported by the thermoformed intermediate catheter. The authors assessed the patient background, procedural outcomes, and postoperative complications. Between October 2013 and June 2022, 43 patients with intracranial tumors and 45 with DAVFs underwent embolization at the authors' institutions. Among these cases, embolization of the ICA side branch feeder was attempted in 10 intracranial tumors and 2 DAVFs. Of these 12 patients, the microcatheter was guided deep enough for successful embolization in 11 cases (92%). Two asymptomatic arteriovenous fistulas were complicated during guidewire manipulation deep in the feeder. Yet, both disappeared completely after glue injection into the feeding artery. No spasm or dissection of the parent artery occurred during the procedure. Postoperative radiological evaluation showed no intracranial hematoma or symptomatic cerebral infarction. One patient (9%) developed permanent postoperative cranial neuropathy that gradually improved after embolization. This study revealed that custom shaping of distal access catheters is an effective technique that enabled the embolization of ILT and MHT feeders with a success rate of more than 90%.

The case of treatment for carotid web - Double-layer micromesh stent implantation in our hospital.

A carotid web is a shelf-like structure on the posterior wall of the origin of the internal carotid artery, and it is believed to cause cerebral infarction due to thrombus formed by turbulent flow with stagnation of blood flow. Recently, it has been suggested that recurrent cerebral infarction cannot be prevented in patients with a symptomatic carotid web by conventional medical management alone. However, there is still no consensus on the treatment of carotid webs. Carotid artery stenting (CAS) with the CASPER stent (Microvention, Terumo, Tustin, CA, USA) was performed in six consecutive patients with symptomatic carotid webs, and the results are reported along with a review of the literature. Six consecutive patients with a diagnosis of internal carotid artery stenosis due to a carotid web on magnetic resonance imaging and digital subtraction angiography (DSA) were included in this study. All patients underwent dual antiplatelet therapy approximately 10 days before surgery and after 6 months, and then, a CASPER stent was implanted under general anesthesia. All patients were evaluated postoperatively by DSA 6 months after treatment. In all patients, no in-stent stenosis was seen 6 months after the operation, and no symptomatic cerebral infarction occurred within 1 year after the procedure. CASPER stent implantation may be effective for treating carotid webs.

Biological Mechanism of Sex Difference in Stroke Manifestation and Outcomes.

Female patients tend to have greater disability and worse long-term outcomes after stroke than male patients. To date, the biological basis of sex difference in ischemic stroke remains unclear. We aimed to (1) assess sex differences in clinical manifestation and outcomes of acute ischemic stroke and (2) investigate whether the sex disparity is due to different infarct locations or different impacts of infarct in the same location. This MRI-based multicenter study included 6,464 consecutive patients with acute ischemic stroke (<7 days) from 11 centers in South Korea (May 2011-January 2013). Multivariable statistical and brain mapping methods were used to analyze clinical and imaging data collected prospectively: admission NIH Stroke Scale (NIHSS) score, early neurologic deterioration (END) within 3 weeks, modified Rankin Scale (mRS) score at 3 months, and culprit cerebrovascular lesion (symptomatic large artery steno-occlusion and cerebral infarction) locations. The mean (SD) age was 67.5 (12.6) years, and 2,641 (40.9%) were female patients. Percentage infarct volumes on diffusion-weighted MRI did not differ between female patients and male patients (median 0.14% vs 0.14%, p = 0.35). However, female patients showed higher stroke severity (NIHSS score, median 4 vs 3, p < 0.001) and had more frequent END (adjusted difference 3.5%; p = 0.002) than male patients. Female patients had more frequent striatocapsular lesions (43.6% vs 39.8%, p = 0.001) and less frequent cerebrocortical (48.2% vs. 50.7% in patients older than 52 years, p = 0.06) and cerebellar (9.1% vs. 11.1%, p = 0.009) lesions than male patients, which aligned with angiographic findings: female patients had more prevalent symptomatic steno-occlusion of the middle cerebral artery (MCA) (31.1% vs 25.3%; p < 0.001) compared with male patients, who had more frequent symptomatic steno-occlusion of the extracranial internal carotid artery (14.2% vs 9.3%; p < 0.001) and vertebral artery (6.5% vs 4.7%; p = 0.001). Cortical infarcts in female patients, specifically left-sided parieto-occipital regions, were associated with higher NIHSS scores than expected for similar infarct volumes in male patients. Consequently, female patients had a higher likelihood of unfavorable functional outcome (mRS score >2) than male patients (adjusted absolute difference 4.5%; 95% CI 2.0-7.0; p < 0.001). Female patients have more frequent MCA disease and striatocapsular motor pathway involvement with acute ischemic stroke, along with left parieto-occipital cortical infarcts showing greater severity for equivalent infarct volumes than in male patients. This leads to more severe initial neurologic symptoms, higher susceptibility to neurologic worsening, and less 3-month functional independence, when compared with male patients.

Abstract TP178: Cerebral Infarction after Hematopoietic Stem Cell Transplantation (HSCT) in Adult Patients with Sickle Cell Disease

Introduction: Symptomatic and silent cerebral infarcts (SCIs) are common in children and adults with sickle cell disease (SCD). SCIs are associated with cognitive performance and risk of future symptomatic stroke. The incidence of overt stroke and SCI post HSCT is low in children, but there is limited information in adults. We sought to determine the impact of HSCT on the rate of new symptomatic and silent cerebral infarcts in adults with SCD. Methods: The study population included patients with SCD (HbSS, HbSC, and HbS/beta-thalassemia) that were enrolled in NIH studies (14-H-0077, 09-H-0225) and underwent HSCT from 2004-19 and received pre- and post-transplant MRI studies. MRI FLAIR, T1, and T2 images were reviewed by two independent readers and scored for presence of prior ischemic stroke and silent cerebral infarct (≥ 3mm on T2 or FLAIR images in 2 imaging planes). Changes in SCIs and ischemic strokes were compared before and after transplantation. Results: Eighty-four patients were included in the study, mean age 32.3 yrs. (range 10-65 yrs.) and 57% male. Median follow-up period was 3.3 yrs. (range: 6 months -17 yrs.) for a total of 412 patient-years. Overall, 60% had evidence of SCI and or prior ischemic stroke at transplant; 54% (45/84) with SCI and 23% with imaging evidence of a prior stroke. During the follow-up period, 13% (11/84) patients developed new ischemic injury, two patients developed a new stroke and nine patients developed new SCIs. The post-HSCT incidence rate of new stroke was 0.49 events/100 patient-years, and SCIs was 2.2 events/100 patient-years. Patients who progressed compared to those who did not were older at transplant (36.1 yrs. vs. 31.2 yrs.; p=0.09), had a prior history of stroke (27% vs. 22%, p=0.71), had a prior history of SCI (64% vs. 52%, p=0.47), and a prior history of stenotic vasculopathy (18% vs. 14%, p= 0.65). Conclusions: The incidence of new ischemic events after HSCT for SCD in adults is low. Our rates are comparable to incidence rates reported in children with SCD after HSCT. While rates of progression were higher in patients with prior stroke, SCI, and vasculopathy, we did not find a significant difference between groups.

Comparison of in-hospital outcomes after coronary artery bypass graft surgery in elders and younger patients: a multicenter retrospective study

ObjectivesWe aimed to identify in-hospital outcomes in young (≤ 65 years) and old (> 65 years) patients after coronary artery bypass grafting (CABG) by analyzing the effect of age on adverse events after on-pump or off-pump CABG.MethodsPatients older than 65 years were defined as older patients and others were defined as younger patients. The qualitative data were compared by chi-square or Fisher's exact tests. The quantitative data were compared by the two-sample independent t-test or Mann–Whitney U test. Multifactor binary logistic regression was used to control for confounders and to investigate the effect of age on dichotomous outcome variables such as death.ResultsIn the on-pump CABG population, the postoperative in-hospital mortality, the incidence of postoperative symptomatic cerebral infarction (POSCI) and postoperative atrial fibrillation (POAF) was higher in older patients than in younger patients (P value < 0.05), and age > 65 years was associated with postoperative in-hospital mortality (OR = 2.370, P value = 0.031), POSCI (OR = 5.033, P value = 0.013), and POAF (OR = 1.499, P value < 0.001). In the off-pump CABG population, the incidence of POAF was higher in older patients than in younger patients (P value < 0.05), and age > 65 years was associated with POAF (OR = 1.392, P value = 0.011).ConclusionIn-hospital outcomes after CABG are strongly influenced by age. In on-pump CABG, the risk of postoperative death, POSCI, and POAF was higher in older patients, and in off-pump CABG, the risk of POAF was higher in older patients.

Comparison of the prognosis of symptomatic cerebral infarction and pulmonary embolism in patients with advanced non-small cell lung cancer.

Lung cancer patients face a high risk of thromboembolism (TE), which is considered to be a poor prognostic factor. However, the impact of symptomatic cerebral infarction (CI) and pulmonary embolism (PE) on the prognosis of advanced non-small cell lung cancer (NSCLC) patients is not fully understood. We retrospectively identified 46 patients with advanced NSCLC who developed symptomatic CI or PE at five hospitals in Japan between January 2010 and December 2019. Prognosis and biomarker levels after incident CI and PE were investigated. Of the 46 patients, 36 developed symptomatic CI, and 10 developed symptomatic PE. The median follow-up duration after incident CI and PE was 18.2months. Although the proportion of Common Terminology Criteria for Adverse Events grade 4 tended to be higher in patients with PE than in those with CI (30% vs. 11%, p=0.16), the overall survival (OS) after incident TE tended to be worse in patients with CI than in those with PE (median 2.3months vs. 9.1 months, log-rank test p=0.17). Multivariate analysis showed that OS after CI was worse in patients with high D-dimer (DD) levels than in those with low DD levels at the time of incident CI (median 1.3months vs. 8.3 months, log-rank p < 0.001). This retrospective study demonstrated that the prognosis of patients tended to be poorer after CI than after PE. The DD levels at the time of incident CI might be a promising predictor of clinical outcomes in advanced NSCLC patients who develop CI.

Long-Term Follow-up of Dutch Patients with Sickle Cell Disease Diagnosed By Newborn Screening - Effect on the Morbidity and Mortality in the Netherlands

Background: Sickle cell disease (SCD) is associated with increased morbidity and mortality compared to the general population. To enable early preventive measures to improve clinical outcome, newborn screening for SCD was introduced in January 2007 in the Netherlands. The objective of this study is to assess the residual risk of death and the incidence of major disease-related complications during the first fifteen years of life in children diagnosed with SCD by newborn screening. Methods: In this prospective, national multicenter cohort study, all children born after 1 January 2007 and diagnosed with SCD by newborn screening were included. Following informed consent, data were collected from medical files on SCD genotype, treatment, mortality and occurrence of major disease-related complications including hospitalization for vaso-occlusive crises (VOC), severe infections (sepsis, meningitis, osteomyelitis) and neurological complications. Overall survival and survival without specific SCD-related complications were analyzed by Kaplan-Meier curves. Results: Preliminary data of 197 (38%) of the 520 eligible subjects from 8 centers in the Netherlands, with a total follow-up of 1,585 patient-years are presented. The median age on July 1st 2022 was 8.0 years (IQR range: 4.0 - 11.0 years). The majority of children (55%) had severe SCD (genotypes HbSS or HbSβ0 thalassemia), the remainder had another genotype including HbSC or HbSβ+ thalassemia. Survival at the age of 15 years was 99.5%. One patient died at the age of 1 year due to pneumococcal sepsis. Eight patients (4%) had a severe infection (meningitis, sepsis, osteomyelitis) caused by Streptococcus Pneumoniae in 3/8 cases with 1 fatal outcome as described above. Two patients experienced a symptomatic cerebral infarction at the age of 11 months and 1.5 years, respectively. Both patients had comorbidities, increasing the risk of a cerebral infarction. The mean survival time without admission for VOC was 7.3 years (95% CI: 6.2-8.5) for HbSS/HbSβ0 thalassemia and 11.5 years (95% CI: 10.1-12.8) for HbSC/HbSβ+ thalassemia, respectively (p < 0.001) (Figure 1). Conclusion: In this Dutch cohort of neonatally screened patients with SCD, infectious complications were the main cause of severe comorbidity and mortality. Further analysis to identify risk factors for infectious complications will be performed in the final analyses to target additional preventive measures that may lower the risk of infection in this specific group of patients. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Intra-arterial Thrombolysis for Acute Retinal Ischemia: A Retrospective, Observational, Cohort Study.

To determine whether intra-arterial thrombolysis (IAT) within 16 hours after the onset of symptoms is feasible and associated with better visual outcomes in patients with acute retinal ischemia (ARI). The retrospective cohort study was performed from January 2014 to December 2021 in the Xuanwu Hospital of Capital Medical University. Patients with ARI who initially presented visual acuity of 20/100 or worse were screened in the study. Visual end points were evaluated at one week and at final visit after treatment. Serious adverse events were recorded during operation and within 1 week after IAT treatment. The amount of clinically significant visual improvement (≥0.3 logarithm of the minimum angle of resolution) in the IAT group was significantly higher than that in the conservative treatment group at one week after the treatment (47.8% vs 16.7%; P = 0.014) and at final visit (52.2% vs 20%; P = 0.014). After controlling confounding factors, ARI treatment was the only factor significantly associated with the amount of clinically significant visual improvement (OR, 4.364; 95 CI, 1.298-14.667; P = 0.017). A patient (4.3%) experienced retinal hemorrhage without symptom within 1 week after IAT treatment. No patients experienced new symptomatic cerebral infarction, intracranial hemorrhage, TIA, artery dissection, vascular perforation, and distal embolization during operation and within 1 week after IAT treatment. IAT may be associated with better visual improvement within 16 hours after the onset of symptoms. Besides, IAT is feasible and associated with a low risk of periprocedural complications for ARI. This study will aid in feasibility testing and sample size calculations in advance of future, fully-powered efficacy studies for ARI.

Cilostazol Administration for Subarachnoid Hemorrhage: A Meta-analysis of Randomized Controlled Trials.

The efficacy of cilostazol administration to treat subarachnoid hemorrhage remains controversial. We conduct a systematic review and meta-analysis to explore the influence of cilostazol administration on treatment efficacy for subarachnoid hemorrhage. We have searched PubMed, Embase, Web of science, EBSCO, and Cochrane Library databases through July 2020 for randomized controlled trials assessing the effect of cilostazol administration in patients with subarachnoid hemorrhage. This meta-analysis is performed using the random-effect model. Four randomized controlled trials involving 405 patients were included in the meta-analysis. Overall, compared with control group for subarachnoid hemorrhage, cilostazol intervention can significantly reduce symptomatic vasospasm (odds ratio [OR], 0.35; 95% confidence interval [CI], 0.21-0.60; P = 0.0001) and cerebral infarction (OR, 0.40; 95% CI, 0.22-0.73; P = 0.003) and improve no or mild angiographic vasospasm (OR, 2.01; 95% CI, 1.19-3.42; P = 0.01) and an mRS score of 2 or less (OR, 2.70; 95% CI, 1.09-6.71; P = 0.03), but revealed no obvious influence on severe angiographic vasospasm (OR, 0.53; 95% CI, 0.27-1.02; P = 0.06). There were no increase in adverse events (OR, 1.17; 95% CI, 0.54-2.52; P = 0.69), hemorrhagic events (OR, 0.62; 95% CI, 0.06-6.27; P = 0.69), and cardiac events (OR, 2.14; 95% CI, 0.44-10.27; P = 0.34) after the cilostazol intervention than control intervention. Cilostazol treatment may be effective to treat subarachnoid hemorrhage in the terms of symptomatic vasospasm, cerebral infarction, no or mild angiographic vasospasm, and an mRS score of 2 or less.

The usefulness and safety of dexmedetomidine for postoperative sedation in pediatric patients with moyamoya disease.

After revascularization surgery in pediatric patients with moyamoya disease (MMD), resting and avoiding crying is important. However, this inaction is often difficult because of pain or anxiety. Dexmedetomidine (DEX), which has sedative and analgesic properties, may be useful in reducing those uncomfortable conditions; however, its common side effects include bradycardia and hypotension, which have a risk of decreasing the cerebral blood flow. The aim of this study was to investigate the efficacy and safety of using DEX for pediatric patients with MMD in the acute period after revascularization surgery. This retrospective study included pediatric patients with MMD who underwent revascularization surgery. Based on whether DEX was used for light sedation during postoperative days (PODs) 0-1 after extubation, the patients were divided into DEX or control groups. For neurological outcomes, the incidence of symptomatic cerebral infarction and transient neurological events (TNEs) during PODs 0-1 and the entire hospitalization were investigated. In addition, the Richmond Agitation-Sedation Scale (RASS) was used to assess the effect of DEX, and bradycardia and hypotension were evaluated as side effects. A total of 84 surgical procedures were included in this study (27 in the DEX group and 57 in the control group). During PODs 0-1, symptomatic infarction was not observed in either group. The incidence of TNEs was almost the same in both groups: 2 (7.4%) of the 27 procedures in the DEX group and 4 (7.0%) of the 57 procedures in the control group (p > 0.99). Moreover, the incidences of symptomatic infarction and TNEs during the entire hospitalization did not differ significantly (symptomatic infarction, p > 0.99; TNEs, p = 0.20). Regarding the DEX effect, the median RASS scores during PODs 0-1 were -1.0 (drowsy) in the DEX group and +1.0 (restless) in the control group, showing a significant difference (p < 0.01). Regarding side effects, bradycardia was observed only in 3 (11.1%) of the 27 procedures in the DEX group (p = 0.03), and hypotension was not observed in any of the cases. In pediatric patients with MMD who are extubated after revascularization surgery, DEX produced appropriate light sedation and analgesia. The risk for symptomatic infarction is almost the same in cases in which DEX is used and those in which it is not; however, neurosurgeons should be cautious of bradycardia and TNEs as potential side effects.

Safety of early posterior fusion surgery without endovascular embolization for asymptomatic vertebral artery occlusion associated with cervical spine trauma.

Vertebral artery occlusion (VAO) is an increasingly recognized complication of cervical spine trauma. However, the management strategy of VAO remains heavily debated. Therefore, the aim of this retrospective study was to investigate the safety of early fusion surgery for traumatic VAO. This study included a total of 241 patients (average age 64.7years; 201 men) who underwent early surgical treatment for acute cervical spine injury between 2012 and 2019. The incidence of VAO, cerebral infarction rates, the recanalization rates, and cerebral thromboembolism after recanalization were retrospectively analyzed. VAO occurred in 22 patients (9.1%). Of the 22 patients with VAO, radiographic cerebral infarction was detected in 4 patients (21.1%) at initial evaluation, including 1 symptomatic medullar infarction (4.5%) and 3 asymptomatic cerebrum infarctions. A patient who experienced right medullar infarction showed no progression of the neurologic damage. Follow-up imaging revealed that the VAOs of 9 patients (40.9%) were recanalized, and the recanalization did not correlate with clinical adverse outcomes. The arteries of the remaining 13 (59.1%) patients remained occluded and clinically silent until the final follow-up (mean final follow-up 33.0months). Despite the lack of a concurrent control group with preoperative antiplatelet therapy or endovascular embolization for VAO, our results showed low symptomatic stroke rate (4.5%), high recanalization rate (40.9%), and low mortality rate (0%). Therefore, we believe that the indication for early stabilization surgery as management strategy of asymptomatic VAO might be one of the safe and effective treatment options for prevention of symptomatic cerebral infarction.

P1502: LONG-TERM FOLLOW-UP OF DUTCH PATIENTS WITH SICKLE CELL DISEASE DIAGNOSED BY NEONATAL SCREENING – EFFECT ON THE MORBIDITY AND MORTALITY IN THE NETHERLANDS.

Background: Sickle cell disease (SCD) is associated with increased morbidity and mortality compared to the general population. To initiate early preventive measures, newborn screening for SCD has been introduced in January 2007 in the Netherlands. Aims: The objective of this study is to assess the effectiveness of this neonatal screening for SCD by describing the residual risks of death and major disease-related events during the first fourteen years of life in children diagnosed with SCD at birth in the Netherlands. Methods: Here we report the first data of the largest center (Amsterdam UMC) of this prospective, national multicenter cohort study. Following informed consent, data were collected from medical files of all children diagnosed by neonatal screening. Descriptive data on SCD genotype and occurrence of major disease-related events are presented, including hospitalization for vaso-occlusive crisis (VOC), acute chest syndrome, severe infections and neurological complications. Overall survival and survival without specific SCD-related complications were analyzed by Kaplan-Meier curves. Results: Up until now, 98 (56%) out of 174 eligible subjects from this institution were included, with a total follow-up of 805 patient-years. The majority (55%) had the severe genotype (HbSS/ beta0-thalassemia), the remainder had genotypes HbSC or HbS/beta+-thalassemia. Survival by the age of 14 was 98.9%, with 1 death at the age of 1 years due to sepsis, most likely related to SCD. Seven patients (7.1%) had a severe infection (meningitis, sepsis, osteomyelitis) caused by Streptococcus Pneumoniae in 3/7 cases. Antibiotic prophylaxis was prescribed for all 7 patients before they reached the age of 1 year, and 6/7 patients had been fully vaccinated with the 23 valent pneumococcal vaccine. Two patients experienced a symptomatic cerebral infarction at the age of 11 months and 1.5 years, respectively. At the age of 10 years the survival without hospitalization for vaso-occlusive crisis was 27% (95% CI: 12.7 – 43.14%) and 51% (25.3 – 72.0%) for the SS/Sβ0 and SC/Sβ+ genotype, respectively. Image:Summary/Conclusion: In this cohort of neonatally screened patients with SCD, the SCD-related mortality and morbidity is still impressive with 1% mortality, 7 severe infections, and 2 patients with a CVA. A final analysis of the effect of neonatal screening for SCD will follow after completion of data collection in all participating centers in the Netherlands.

Intravenous landiolol for the prevention of atrial fibrillation after aortic root, ascending aorta, and aortic arch surgery: A propensity score-matched analysis

ObjectivePostoperative atrial fibrillation (POAF) after cardiac surgery is associated with increased mortality. The efficacy of landiolol hydrochloride for POAF prevention after coronary artery bypass grafting procedure and valve surgery has been reported. However, little evidence is available on its role in POAF prevention after aortic root, ascending aorta, and aortic arch surgery. This study aimed to determine the association between intravenous landiolol and the incidence of POAF after these aortic surgeries. MethodsWe included 358 consecutive adult patients without preoperative atrial fibrillation who underwent aortic root, ascending aorta, and aortic arch surgery between January 1, 2011, and December 31, 2018, at our institution. The therapeutic influence of landiolol in preventing POAF was estimated by propensity score-matched analysis (n = 222). The primary end point was the incidence of POAF within 72 hours after surgery. The secondary end points included adverse clinical events such as 30-day mortality and symptomatic cerebral infarction. ResultsThe median age of the cohort was 72 years, 68.5% were men, and 46.4% received postoperative oral or transdermal β-blockers. After minimizing differences in patient background by propensity score matching, the incidence of POAF in the landiolol group was significantly lower than that in the reference group (18.9% vs 38.7%; P = .002). Landiolol use was associated with reduced incidence of POAF (odds ratio, 0.39; 95% CI, 0.21 to −0.72; P = .003). There were no significant differences in secondary end points. ConclusionsIntravenous landiolol was associated with a lower incidence of POAF after aortic root, ascending aorta, and aortic arch surgery.

Single direct right axillary artery cannulation using a modified Seldinger technique in minimally invasive cardiac surgery.

Single direct right axillary artery cannulation is uncommon in minimally invasive cardiac surgery; however, the risk of cerebral infarction due to retrograde perfusion using the femoral artery remains high in patients with thoracoabdominal aortic atheroma. In our institution, we perform right axillary artery cannulation using a modified Seldinger technique in patients with atherosclerotic disease. This study aimed to evaluate the safety and effectiveness of this technique in minimally invasive cardiac surgery. Data of all peripheral cannulation cases in patients who underwent minimally invasive cardiac surgery between March 2014 and December 2019 were obtained from our institutional database. Right axillary artery cannulation was successfully performed in 175 patients, 112 of whom underwent magnetic resonance imaging. Procedures comprised single-valve 86.3% (n = 151, 86.3%), double-valve (n = 21, 12%), and triple-valve (n = 3, 1.7%) surgeries. In-hospital mortality rate was 1.7% (n = 3). Stroke rate was 1.1% (n = 2); these 2 patients developed stroke at 3 and 5days postoperatively. Forty-one (36.9%) patients were diagnosed with silent brain infarction on postoperative magnetic resonance imaging. There were no instances of intraoperative local axillary arterial injury, dissection, rupture, or surgical wound infection. Two patients had axillary wound hematoma and 2 had temporary right limb neuropathy, which resolved before discharge. No cases of pseudoaneurysm were found at the cannulation site. Limb ischemia and compartment syndrome were not reported. There were no complications of postoperative symptomatic cerebral infarction following minimally invasive cardiac surgery with single direct right axillary artery cannulation using a modified Seldinger technique, even though patients had significant atherosclerotic vascular disease.

A novel modular inner aortic arch stent-graft for localized Stanford type A aortic dissection aneurysm with short healthy proximal ascending aorta

Central MessageA novel modular inner aortic arch stent-graft system simplified our procedure and provided a novel therapeutic strategy for ascending and aortic arch lesions with short healthy ascending aorta. A novel modular inner aortic arch stent-graft system simplified our procedure and provided a novel therapeutic strategy for ascending and aortic arch lesions with short healthy ascending aorta. A 53-year-old man was admitted with chronic localized Stanford type A aortic dissection aneurysm (maximum diameter of 60.2 mm) with a 3-year history of hypertension and cerebral infarction. Preoperative computed tomography angiography showed the primary entry tear originated in the ascending aorta (Figure 1, A). The lengths of total ascending aorta and the proximal healthy ascending aorta were 92.1 mm and 24.0 mm, respectively. The diameter of proximal landing zone is 40.0 mm. The orifice diameters of the innominate artery (IA), left common carotid artery (LCCA), and left subclavian artery (LSA) were 14.0 mm, 7.7 mm, and 13.2 mm, respectively. Given the high risk of rupture and cerebral infarction, and the patient's refusal of transfusion for personal beliefs, we performed endovascular repair using a novel modular aortic arch stent-graft system (WeFlow-Arch; Hangzhou Endonom Medtech Co., Ltd.) (Figure 1, E and F). Since the diameter of LCCA was significantly smaller than LSA, IA and LSA were used for revascularization of supra-aortic arteries after LCCA-LSA bypass. Puncture access included: (1) left brachial artery for bridging LSA with one inner branch, (2) right common carotid artery for bridging innominate artery with another inner branch, (3) right femoral artery for implanting the main stent-grafts, and (4) left femoral vein for rapid pacing. A low transverse cervical incision was performed to expose common carotid arteries of both sides and LSA. A bypass between LCCA and LSA was performed and the proximal segment of the LCCA was planned to ligate. The endovascular procedural process is shown in Video 1. The first module, ascending aorta stent-graft (44 × 44 mm in diameter, 50 mm in length, 12 mm in diameter of inner branch), in the precurved delivery system, via femoral artery access was deployed into the ascending aorta under rapid pacing of a preset temporary pacemaker (Figure 1, C). The second modules, bridging covered stents, were deployed for bridging the supra-aortic branches and the 2 inner branches, including one 13-mm × 16-mm × 100-mm covered stent for bridging IA and two 13-mm × 13-mm × 80-mm covered stents for bridging LSA. The third module, aortic arch stent-graft (44 mm × 32 mm in diameter, 200 mm in length), was overlapped with the lumen of the first module via steerable delivery system to avoid iatrogenic migration of the first module (Figure 1, D). Segmental deployment simplified the procedures associated with complicated anatomic matching and avoided the long-time interruption of the supra-aortic blood supply. The patient was free from postprocedural symptomatic cerebral infarction. 12-month follow-up computed tomography angiography confirmed patency of the stent-graft branches, no endoleak or retrograde dissection, and complete thrombosis of false lumen with a maximum aneurysm diameter of 60.0 mm (Figure 1, B). This case indicated that this modular endograft simplified aortic arch repair procedure and provided a novel therapeutic strategy for ascending and aortic arch lesions with short healthy ascending aorta. This case was part of a clinical trial (NCT04764370), namely Guo's Aortic Arch Reconstruction: The First in Man Study of WeFlow-Arch Modular Embedded Branch Stent Graft System. This study was reviewed and approved by Chinese PLA General Hospital Medical Ethics Committee (approval number: S2018-230-01, approval date: February 28, 2019) and informed consent was taken from the patient. https://www.jtcvstechniques.org/cms/asset/59e4aa36-84b1-4a38-86a6-e0f080c88901/mmc1.mp4Loading ... Download .mp4 (27.07 MB) Help with .mp4 files Video 1Endovascular procedure. LCCA, Left common carotid artery; LSA, left subclavian artery; IA, innominate artery; RCCA, right common carotid artery; RAO, right anterior oblique; CAU, caudal oblique. Video available at: https://www.jtcvs.org/article/S2666-2507(22)00347-9/fulltext. Download .jpg (.09 MB) Help with files Video 1Endovascular procedure. LCCA, Left common carotid artery; LSA, left subclavian artery; IA, innominate artery; RCCA, right common carotid artery; RAO, right anterior oblique; CAU, caudal oblique. Video available at: https://www.jtcvs.org/article/S2666-2507(22)00347-9/fulltext.

Application of hybrid surgery in the clipping of large complex paraclinoid aneurysms

Nine patients with large complex paraclinoid aneurysms were treated by hybrid surgery in the Second Affiliated Hospital of Zhejiang University between January 2016 and July 2021. Intraoperative angiography was conducted for real-time evaluation of the aneurysm and its clipping efficacy. A total of 8 aneurysms were clipped under temporary proximal control with balloon occlusion. Suction decompression was simultaneously applied in 2 of these cases. After surgery, 2 patients developed symptomatic cerebral infarction, 3 patients developed transient oculomotor nerve palsy, but no patients had vision deterioration. Postoperative follow-up showed that small neck residue occurred in 1 case, but with the rest of aneurysms were completely occluded without parent artery stenosis. Hybrid surgery was proved to be advantageous in real-time assessment of aneurysm morphology and clipping efficacy. Combination of temporary proximal balloon occlusion and suction decompression technique can help in reducing the difficulty of aneurysm exposure and remodeling, thereby improving the outcome and decreasing the complications.

What is the subtype of dementia in patients with fragility hip fracture?

IntroductionCognitive function is an important factor that affects functional recovery after hip fracture (HipFx) surgery. The literature on the pathophysiology of dementia in HipFx patients is scarce. We performed a differential diagnosis of dementia in HipFx patients using clinical and brain MRI findings.MethodsThis is a prospective study in which brain MRI was evaluated for patients with HipFx for research purposes. One-hundred-and-five HipFx patients (85 females and 20 males) who underwent surgery and were subsequently able to undergo brain MRI at our hospital were evaluated. The mean age was 84 years. The presence of dementia was determined based on clinical findings and whether the patient meets its diagnostic criteria according to the International Classification of Diseases 10th Edition (ICD-10). The differential diagnosis of dementia was made based on brain MRI findings and the dementia diagnostic flow chart published in the Clinical Practice Guideline for Dementia 2017 (Japanese Society of Neurology). The Voxel-based Specific Regional Analysis System for Alzheimer’s Disease (VSRAD) advance 2 diagnostic software was used to evaluate atrophy of the para-hippocampal gyrus.ResultsFifty-six (53%) patients were clinically diagnosed with dementia according to the ICD-10 criteria. The MRI findings were diverse: Alzheimer’s disease (AD)-type, asymptomatic multiple ischemic cerebral lesions, past symptomatic cerebral infarction or cerebral hemorrhage, Binswanger’s disease (BW)-type, chronic subdural hematoma, disproportionately enlarged subarachnoidal hydrocephalus (DESH), and their combinations thereof. A combination of MRI and clinical findings of dementia patients demonstrated the following distribution of dementia subtypes: AD (n = 20), vascular dementia (n = 33), AD and BW vascular dementia (n = 3).ConclusionThis study revealed that the brain MRI findings of HipFx patients were diverse. Although vascular dementia is found to be common in this particular population, this could be an incidental finding. Further study is warranted to clarify the specificity of our findings by increasing the number of patients, setting the control, and investigating whether dementia subtypes affect postoperative gait acquisition and fall risk.