Symptomatic Infarction Research Articles

Cardiac Troponin I after Carotid Endarterectomy in Different Cardiac Risk Patients

We compared postoperative cardiac damage, defined as cardiac troponin I (cTnI) elevation, in low, medium, and high cardiac risk patients, after carotid endarterectomy (CEA). The Vascular Study Group of New England Cardiac Risk Index (VSG-CRI) criteria for stratifying patients considered for vascular surgery into low, medium, and high cardiac risk groups were used prospectively. For all patients (n = 324), cTnI value assessments were made before surgery and on postoperative days 1, 3, and 7. Postoperative cTnI values ranging from .05 to .5 ng/mL were classified as myocardial ischemia; values more than .5 ng/mL were classified as myocardial infarction. Cardiac damage was defined as either myocardial ischemia or infarction. Mortality was .003%, stroke rate was null, and symptomatic myocardial infarction was null as well. Low-risk patients (16 of 140) and medium-risk patients (28 of 160) increased their troponin levels on days 1 and 3 postoperatively. However, none of the high-risk patients (n = 24) showed any postoperative cardiac damage. Low and medium cardiac risk patients showed higher troponin values on each separate day, in comparison with high cardiac risk patients. CEA is followed by a high incidence of asymptomatic cTnI increase that is associated with late cardiac events. However, high cardiac risk patients as defined by the VSG-CRI criteria do not seem to suffer higher cardiac damage after CEA compared with low and medium cardiac risk patients.

Comparison of Long-Term Clinical Outcomes after Drug-Eluting Stent Implantation in Patients with Coronary Artery Disease with and without Prior Cerebral Infarction.

To compare the clinical and angiographic outcomes after implantation of drug-eluting stents (DESs) in patients with coronary artery disease (CAD) with or without prior cerebral infarction. Ninety-eight consecutive patients (130 lesions) who underwent successful coronary DES implantation were prospectively classified into two groups: those with a clinical history of symptomatic cerebral infarction (cerebral infarction group, 49 patients, 69 lesions) and those without a clinical history of symptomatic cerebral infarction (noncerebral infarction group, 49 patients, 61 lesions). The primary endpoint was defined as death, nonfatal myocardial infarction, and cerebrovascular events. The Kaplan-Meier method was used to create a primary endpoint curves to determine the time-dependent cumulative primary endpoint-free rate, which were compared using the log-rank test. The incidence of primary endpoints was higher in the cerebral infarction group than in the noncerebral infarction group (p = 0.0075). The Cox proportional hazards regression model for primary endpoint identified prior cerebral infarction (p = 0.0331, hazard ratio = 2.827) and patients with peripheral artery disease (p = 0.0271, hazard ratio = 2.757) as explanatory factors. The results showed that clinical outcomes were poorer in patients with CAD who had prior cerebral infarctions than in those who did not have infarction.

Prevention and Management of Cerebral Small Vessel Disease.

Lacunar infarcts/lacunes, white matter hyperintensities (WMH), and cerebral microbleeds (CMBs) are considered various manifestations of cerebral small vessel disease (SVD). Since the exact mechanisms of these manifestations differ, their associated risk factors differ. High blood pressure is the most consistent risk factor for all of these manifestations. However, a "J curve" phenomenon in terms of blood pressure probably exists for WMH. The association between cholesterol levels and lacunar infarcts/lacunes or WMH was less consistent and sometimes conflicting; a low cholesterol level probably increases the risk of CMBs. Homocysteinemia appears to be associated with WMH. It is noteworthy that the risk factors profile may also differ between different lacunar patterns and CMBs located at different parts of the brain. Thrombolysis, antihypertensives, and statins are used to treat patients with symptomatic lacunar infarction, just as in those with other stroke subtypes. However, it should be remembered that bleeding risks increase in patients with extensive WMH and CMBs after thrombolysis therapy. According to the Secondary Prevention of Small Subcortical Strokes trial results, a blood pressure reduction to <130 mmHg is recommended in patients with symptomatic lacunar infarction. However, an excessive blood pressure decrease may induce cognitive decline in older patients with extensive WMH. Dual antiplatelet therapy (aspirin plus clopidogrel) should be avoided because of the excessive risk of intracerebral hemorrhage. Although no particular antiplatelet is recommended, drugs such as cilostazol or triflusal may have advantages for patients with SVD since they are associated with less frequent bleeding complications than aspirin.

Leucoariaosis influence on cognitive status of patients with lacunar brain infarcts

Leukoaraiosis is a change in brain white matter with characteristic manifestation in MR and CT head scans. Common leukoaraiosis risk factors include aging and arterial hypertension. A quarter of symptomatic ischemic infarcts belongs to small blood vessel disease group and could be presented as lacunar infarcts. These two crucial pathophysiological mechanisms are in the root of cognitive dysfunction related to small blood vessel disease. 60 lacunar infarct patients were examined and parameters for groups with and with-out leukoaraiosis were determined. It was found that leukoaraiosis incidence was highest in the group of women older than 70. Neurological assessment was scored on NIH-NINDS scale, functional status was scored with Barthelo index, and cognitive status was determined using Mini Mental State Examination (MMSE) and Alzheimer Disease Assessment Scale Late (ADAS-L). Correlation analysis of these parameters on significance level of *p<0.05, **p<0.01, suggests decrease in neurological status and cognitive performance.

Evaluation and management of plaque protrusion or thrombus following carotid artery stenting.

Carotid artery stenting (CAS) has become a common treatment for carotid artery stenosis. However, complications, such as an ischemic event, can occur with CAS during intra- and post-operative periods. Among these ischemic complications, plaque protrusion into the stent and thrombus on the stent have occurred after CAS. We retrospectively evaluated the temporal profile and treatment options for these complications in 32 consecutive cases who underwent CAS at our hospital between April 2009 and December 2011. The cases were evaluated pre-operatively for risk factors, as well as the plaque morphology and characteristics using computed tomographic angiography (CTA), ultrasound (US), and magnetic resonance imaging (MRI). Post-operatively, lesions were examined by CTA and/or US within 1 week of CAS. As a result, among the 32 cases, 8 experienced plaque protrusions or thrombus, which were treated with medication (anti-platelet and/or anti-coagulation reinforcement). In 7 of these 8 cases, the plaque protrusion or thrombus was stabilized with medication alone. However, the remaining case showed growth and migration of the plaque protrusion or thrombus when treated with medication alone, and therefore, required further endovascular treatment. We identified that a history of symptomatic cerebral infarction and plaques with ulceration were risk factors for plaque protrusion or thrombus formation after CAS, and pre dilatation can decrease the risk of these complications. Medication was effective in most cases of plaque protrusion or thrombus; however, further endovascular treatment was required when medication alone was unsuccessful.

Single coronary artery arising from the right coronary sinus with mid-left anterior descending artery segment courses through the ventricular myocardium: A rare entity

Introduction: Congenital anomalies of the coronary artery have an incidence of 1% and isolated single coronary artery without other congenital cardiac anomalies has an approximate incidence of 0.024-0.066% in general population. This rare entity can be diagnosed incidentally during life, however may lead to symptomatic or asymptomatic myocardial infarction and sudden heart attack, even among young athletes. The prognosis varies according to the anatomic distribution, associated atheromatous disease and associated vascular anomalies. Case Report: A 45 years old male with presentation of a single coronary artery from the right coronary sinus with subsequent coursing between the aorta and pulmonary trunk arteries and mid anterior descending artery segment course through the myocardium. Patient presented with non-typical angina symptoms, normal resting electrocardiograph, myocardial perfusion scintigraphy suspect to reduced left ventricular blood flow but negative angiographic evaluation. Conclusion: Thin bridges cannot be demonstrable angiography, so anatomic and panoramic CT-evaluation give more information especially if associated with functional evaluation. Knowledge of physiology, normal and variant anatomy, is most important in managing congenital and acquired disease, and variation in coronary arterial patterning is frequent.

Transfusion in cold autoimmune haemolytic anaemia - a balancing ACT

We present a case of difficult-to-treat idiopathic cold autoimmune haemolytic anaemia complicated by the sequelae of severe normocytic anaemia and alloantibody formation as a result of transfusion. A 26-year-old previously well female presented with symptomatic anaemia and jaundice. Investigations were consistent with cold autoimmune haemolytic anaemia with intravascular haemolysis and a haemoglobin of 47 g/L. No underlying cause was found. She was treated with prednisolone, rituximab, intravenous immunoglobulin, eculizumab, fludarabine and plasma exchange. She required 24 units of red blood cells until she eventually responded to treatment. During this time, however, her haemoglobin nadir was 27 g/L. She suffered a symptomatic non-ST elevation myocardial infarction and visual blurring due to retinopathy of anaemia. Transfusion in this patient was also not without complication. The patient experienced a mild, but symptomatic haemolytic transfusion reaction due to the development of a red cell alloantibody after a transfusion episode. This case highlights the difficult decision of when to transfuse and the risk of under-transfusion in the management of haemolytic anaemia.

Influence of the concomitant use of heparin on the effects of warfarin during catheter ablation for atrial fibrillation.

Warfarin is widely used to perform catheter ablation for atrial fibrillation (AF). Heparin is usually administered during this procedure to prevent thromboembolic events, while protamine is used to reduce the incidence of bleeding complications. The purpose of this study was to investigate the influence of heparin and protamine administration on the effects of warfarin and its safety. The subjects included 226 AF patients (206 males, 54.9 ± 9.1 years, paroxysmal/persistent AF: 118/108) undergoing AF ablation with the discontinuation of warfarin administration over 2 days. Heparin was administered to achieve an activated clotting time (ACT) above 300 s during the procedure. Several parameters of the coagulation status, including the prothrombin time international normalized ratio (PT-INR) and ACT values, measured immediately before and after protamine infusion were compared. The mean value of PT-INR prior to ablation was 1.9 ± 0.6. At the end of the procedure, the mean ACT and PT-INR values were 348.0 ± 52.9 and 2.9 ± 0.7, respectively. Following the infusion of 30 mg of protamine, both the ACT and PT-INR values significantly decreased, to 159.6 ± 31.0 (p < 0.0001) and 1.6 ± 0.3 (p < 0.0001), respectively. No cases of symptomatic cerebral infarction were observed, although femoral hematomas developed in 17 (7.5 %) of the patients without further consequence. The concomitant use of heparin augments the effect of warfarin. Meanwhile, protamine administration immediately reverses both the ACT and PT-INR, indicating the applicability of protamine for AF ablation in patients under the mixed administration of heparin and warfarin.

Preliminary investigation of high-dose tranexamic acid for controlling intraoperative blood loss in patients undergoing spine correction surgery

Background contextWith a significant increase in the number and complexity of spinal deformity corrective surgeries, blood loss, often requiring massive intraoperative transfusions, becomes a major limiting factor during surgery. This scenario is particularly during posterior vertebral column resection (PVCR), where extensive intraoperative blood loss may pose a major risk to the patient, preventing smooth execution of the procedure. Tranexamic Acid (TXA) has been used in cardiac and orthopedic surgeries, including major spinal surgeries, to reduce blood loss and transfusion requirements for decades. PurposeTo assess the efficacy and safety of high doses of TXA in posterior spinal deformity corrective surgery, including PVCR procedures. Study designA retrospective study from a single institution. Patient sampleFifty-nine patients (age range 7 to 46 years old) with spinal deformities undergoing spinal corrective surgeries were included. The patients were divided into two groups: the TXA group (total of 26 patients, including 8 PVCR patients) and the control group (total of 33 patients, including 9 PVCR patients). Outcome measuresThe analyzed outcome measures included estimated intraoperative blood loss, real blood loss (RBL; blood loss/blood volume×100%), blood transfusion requirements, coagulation parameters, complete blood count, liver function, and renal function. Lower limb vein thrombus, symptomatic pulmonary embolism, symptomatic myocardial infarction, seizures, and acute renal failure were also recorded. MethodsBefore skin incision, the patients in the TXA group received an intravenous loading dose of 100 mg/Kg over a 20-minute period, followed by a maintenance infusion of 10 mg/Kg/h until skin closure was completed. The patients in the control group received saline infusion of a similar volume. Statistics included estimated intraoperative blood loss, RBL, blood transfusion requirements, coagulation parameters, complete blood count, liver function, and renal function. All patients in this study were also carefully monitored for consciousness level, breathing status, chest tightness or pain, and urine output after surgery. These were done to detect the presence or absence of pulmonary embolism, myocardial infarction, seizures, and acute renal failure. Patients treated with TXA were examined via vascular ultrasound before and after surgery. ResultsThere were no significant differences in the demographic or surgical traits between the two groups. The blood loss of the patients in the TXA group was 2,441±1,666 mL, whereas that of the control group patients was 4,789±4,719 mL. The difference was statistically significant (p<.05). The average RBL of the patients in the TXA group was 80.6%±49.6% versus 160.8%±163.1% in the control group (p<.05). The blood transfusion requirements for the patients in the TXA group were significantly less than that in the control group (p<.05). Blood loss, RBL, and blood transfusion requirements were all significantly lower in the TXA group, compared with the control group among both PVCR patients and non-PVCR patients. In the TXA group, there was an average of 57.4% reduced blood loss in patients who received PVCR and 39.8% in patients not receiving PVCR. There were no differences in liver and renal functions between the TXA and control groups. There was no lower limb vein thrombus, symptomatic myocardial infarction, symptomatic pulmonary embolism, seizures, or acute renal failure reported in the TXA group. ConclusionsIn our study, high doses of TXA have been shown to effectively control blood loss and reduce the transfusion requirement. This effect was more apparent in patients receiving PVCR. No adverse drug reaction was recorded in the study. In the future, prospective randomized controlled trials to validate our results will be necessary. Future studies conducted on older patient cohort may also be necessary to confirm the safety of extending the use of TXA to the older patients.

Abstract 11236: Prevalence and Risk Factors of Catheterization-Related Cerebral Infarction: Evaluation at Diffusion-Weighted Magnetic Resonance Imaging

Introduction: Due to improvements of catheter design and approach, catheterization-related cerebral infarctions are expected to decrease, whereas this may be counterbalanced by increased risk profile of patients who undergo catheterization. Aims: The aim of this study is to examine the prevalence and risk factors of symptomatic and asymptomatic catheterization-related cerebral infarctions in the contemporary era, using diffusion-weighted magnetic resonance imaging (MRI). Methods and Results: We retrospectively analyzed 84 patients who underwent 1237 diagnostic and interventional catheterization procedures conducted within 2010 and 2011 in our hospital and who obtained the MRI within 14 days after catheterization. Among these, 10 patients developed a neurological event underwent MRI for suspected cerebral infarction (group A), whereas 74 patients were asymptomatic and underwent MRI for various reasons (group B); 52% of patients for the assessment before coronary bypass or surgery of aortic valve, 19% for the systemic vascular assessment for atherosclerotic diseases, and 28% for other reasons. The MRI revealed a fresh cerebral infarction in 5 patients in group A and 22 patients (29.7%) in group B. In patients with infarct lesions, more number of catheters were used (p=0.01), the intravascular procedure was longer (mean ± SEM, 17.1 ± 1.7 minutes vs. 22.7 ± 2.4 minutes, p=0.06), and the mean age tended to be higher (mean ± SEM, 74.1 ± 1.67 vs. 70.4 ± 1.1, p=0.07). The features of infarction were as follows: 62.9% of patients had multiple lesions and relatively small lesions in asymptomatic patients compared to those in symptomatic patients. Conclusions: Symptomatic cerebral infarction occurred after 5 of 1237 (0.4%) procedures. However, the rate of asymptomatic catheterization-related cerebral infarctions detected using diffusion-weighted MRI remains high in high-risk patients or candidates for cardiac surgery, when the rate is compared to that reported by previous studies conducted around 10 years ago. More number of catheters used and longer procedure time were associated with cerebral infarction in present study and careful procedural planning is warranted.

Effects of long-term blood pressure lowering and dual antiplatelet treatment on cognitive function in patients with recent lacunar stroke: a secondary analysis from the SPS3 randomised trial

The primary outcome results for the SPS3 trial suggested that a lower systolic target blood pressure (<130 mm Hg) might be beneficial for reducing the risk of recurrent stroke compared with a higher target (130-149 mm Hg), but that the addition of clopidogrel to aspirin was not beneficial compared with aspirin plus placebo. In this prespecified secondary outcome analysis of the SPS3 trial, we aimed to assess whether blood pressure reduction and dual antiplatelet treatment affect changes in cognitive function over time in patients with cerebral small vessel disease. In the SPS3 trial, patients with recent (within 6 months) symptomatic lacunar infarcts from 81 centres in North America, Latin America, and Spain were randomly assigned, in a two-by-two factorial design, to target levels of systolic blood pressure (1:1; 130-149 mm Hg vs <130 mm Hg; open-label) and to a once-daily antiplatelet treatment (1:1; aspirin 325 mg plus clopidogrel 75 mg vs aspirin 325 mg plus placebo; double-blind). For this analysis, the main cognitive outcome was change in Cognitive Abilities Screening Instrument (CASI) during follow-up. Patients were tested annually for up to 5 years, during which time the mean difference in systolic blood pressure was 11 mm Hg (SD 16) between the two targets (138 mm Hg vs 127 mm Hg at 1 year). We used linear mixed models to compare changes in CASI Z scores over time. The SPS3 trial is registered with ClinicalTrials.gov, number NCT00059306. The study took place between March 23, 2003, and April 30, 2012. 2916 of 3020 SPS3 participants (mean age 63 years [SD 11]) with CASI scores at study entry were included in the analysis, with a median follow-up of 3·0 years (IQR 1·0-4·9). Mean changes in CASI Z scores from study entry to assessment at years 1 (n=2472), 2 (n=1968), 3 (n=1521), 4 (n=1135), and 5 (n=803) were 0·12 (SD 0·83), 0·15 (0·84), 0·16 (0·95), 0·19 (0·99), and 0·14 (1·09), respectively. Changes in CASI Z scores over time did not differ between assigned antiplatelet groups (p=0·858) or between assigned blood pressure target groups (p=0·520). There was no interaction between assigned antiplatelet groups and assigned blood pressure target groups and change over time (p=0·196). Cognitive function is not affected by short-term dual antiplatelet treatment or blood pressure reduction in fairly young patients with recent lacunar stroke. Future studies of cognitive function after stroke should be of longer duration or focus on patients with higher rates of cognitive decline. US National Institute of Neurological Disorders and Stroke.

Relationship between Watershed Infarcts and Recent Intra Plaque Haemorrhage in Carotid Atherosclerotic Plaque

ObjectiveWatershed infarcts (WSI) are thought to result from hemodynamic mechanism, but studies have suggested that microemboli from unstable carotid plaques may distribute preferentially in watershed areas, i.e., between two cerebral arterial territories. Intraplaque haemorrhage (IPH) is an emerging marker of plaque instability and microembolic activity. We assessed the association between WSI and IPH in patients with recently symptomatic moderate carotid stenosis.Methods and ResultsWe selected 65 patients with symptomatic moderate (median NASCET degree of stenosis = 31%) carotid stenosis and brain infarct on Diffusion-Weighted Imaging (DWI) on Magnetic Resonance Imaging (MRI) from a multicentre prospective study. Fourteen (22%) had WSI (cortical, n = 8; internal, n = 4; cortical and internal, n = 2). Patients with WSI were more likely to have IPH than those without WSI although the difference was not significant (50% vs. 31%, OR = 2.19; 95% CI, 0.66–7.29; P = 0.20). After adjustment for degree of stenosis, age and gender, the results remained unchanged.ConclusionAbout one in fifth of brain infarcts occurring in patients with moderate carotid stenosis were distributed in watershed areas. Albeit not significant, an association between IPH - more generally plaque component - and WSI, still remains possible.

Stroke : Highlights of Selected Articles

HomeStrokeVol. 45, No. 10Stroke: Highlights of Selected Articles Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBStroke: Highlights of Selected Articles Originally published1 Oct 2014https://doi.org/10.1161/STROKEAHA.114.007187Stroke. 2014;45:2855Copeptin for the Prediction of Recurrent Cerebrovascular Events After Transient Ischemic Attack: Results From the CoRisk StudyCopeptin is a stress hormone that has previously been shown to be associated with recurrent cerebrovascular events after transient ischemic attack (TIA). The ABCD2 (age, blood pressure, clinical features, duration, diabetes) score and the ABCD3-I (ABCD2 plus dual TIA) score both provide risk assessment for recurrent stroke after TIA. The current study aimed to determine the effect of copeptin in the prediction of recurrent cerebrovascular events (stroke or TIA) within 3 months of TIA. In their cohort, 28 of 302 (9.3%) patients had a recurrent cerebrovascular event within 3 months of TIA. There was no statistically significant difference in copeptin levels in patients with or without recurrent cerebrovascular events. A total of 11 patients had recurrent stroke within 3 months. Copeptin levels were >4× higher in patients with recurrent stroke in comparison with those without stroke. A 10-fold increase in copeptin was associated with an odds ratio of stroke of 3.39 after adjustment for the ABCD2 score. Copeptin increased the prognostic ability of the ABCD2 score in predicting recurrent stroke in 31.2% of patients. In sum, copeptin seems to represent a biomarker with strong prediction value for recurrent stroke after TIA. Further validating studies are needed. But at this time it seems to add in risk stratification of patient presenting with TIA. See p 2918.Long-Term Outcomes After Combined Revascularization Surgery in Adult Moyamoya DiseaseMoyamoya disease is an idiopathic condition of progressive occlusions of both internal carotid arteries with abnormal vascular networks. Controversy exists on the optimal revascularization procedure in adults with moyamoya disease. The authors of this study report on the outcomes of combined revascularization surgery (direct bypass between the superficial temporal artery and a cortical branch of the MCA and indirect bypass known as encephalodurogaleosynangiosis) done on 77 hemispheres in 60 patients. The clinical status of patients, as assessed by the modified Rankin Scale and the Karnofsky Performance Scale, improved until 6 months after surgery and stayed stable after that. The relative revascularization area significantly increased in the long-term compared with the short-term follow-up period. The cerebral blood flow as measured by single photon emission computed tomography improved significantly in the short-term compared with the preoperative period and remained stable after that. Perioperative cerebral infarcts occurred in 13% of cases. However, the long-term risk of stroke was low with the annual rates of symptomatic cerebral hemorrhage and infarction in the operated hemispheres as 0.4% and 0.2%, respectively. In sum, this study showed improvement in clinical, angiographic, and hemodynamic states after combined revascularization surgery in moyamoya disease. However, there is no comparative arm. And thus further study will most definitely be needed to best define the optimal surgical procedure in this patient population. See p 2983.Early Deterioration After Thrombolysis Plus Aspirin in Acute Stroke: A Post Hoc Analysis of the Antiplatelet Therapy in Combination With Recombinant t-PA Thrombolysis in Ischemic Stroke TrialAddition of aspirin within 90 minutes after intravenous thrombolysis (IVT) in acute ischemic stroke has previously been shown to increase the risk of symptomatic intracranial hemorrhage (SICH) while having no effect on 3-month functional outcome in the Antiplatelet Therapy in Combination With Recombinant t-PA Thrombolysis in Ischemic Stroke (ARTIS) trial. The authors explored a post hoc analysis on the effect of aspirin on early neurological deterioration (END). END was defined as ≥4 points on the National Institutes of Health Stroke Scale worsening <24 hours after IVT and further divided into SICH and cerebral ischemia. A total of 31 of 640 patients (4.8%) receiving early aspirin after IVT experienced END: 14 because of SICH and 17 because of cerebral ischemia. On univariate analysis, aspirin increased the risk of END because of SICH but not of END because of cerebral ischemia. After multivariate analysis, aspirin remained significantly associated with END because of SICH. In summary, this post hoc analysis of the ARTIS trial shows that early aspirin after IVT is associated with early neurological deterioration because of symptomatic intracranial hemorrhage and has no beneficial effect on early neurological deterioration because of cerebral ischemia. Although the available literature suggests that early aspirin after IVT in acute ischemic stroke is harmful, further study is needed as there may potentially be certain subgroups of patients with stroke who may benefit from its use. See p 3080. 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Long-term outcomes after combined revascularization surgery in adult moyamoya disease.

The surgical outcomes of adult moyamoya disease are rarely reported. We aimed to evaluate the long-term outcomes of combined revascularization surgery in patients with adult moyamoya disease. Combined revascularization surgery consisting of superficial temporal artery-middle cerebral artery anastomosis with encephalodurogaleosynangiosis was performed on 77 hemispheres in 60 patients. Clinical, angiographic, and hemodynamic states were evaluated retrospectively using quantitative methods preoperatively and postoperatively in the short-term (≈6 months) and long-term (≈5 years) periods. The mean clinical follow-up duration was 71.0±10.1 months (range, 60-104 months). Clinical status improved until 6 months after surgery and remained stable thereafter, as assessed by the Karnofsky Performance Scale and modified Rankin Scale. The revascularization area relative to supratentorial area significantly increased in the long-term period compared with that in the short-term period (54.8% versus 44.2%; P<0.001). Cerebral blood flow in the territory of the middle cerebral artery improved in the short-term period compared with that in the preoperative period (68.7 versus 59.1; considering blood flow of the pons as 50; P<0.001) and thereafter became stable (65.5 in the long term; P=0.219). The annual risks of symptomatic hemorrhage and infarction were 0.4% and 0.2%, respectively, in the operated hemispheres. Combined revascularization surgery resulted in satisfactory long-term improvement in clinical, angiographic, and hemodynamic states and prevention of recurrent stroke.

E-039 Safety and Efficacy of Flow Diverter Treatment for Carotid-Ophthalmic Aneurysms

Introduction/purposeThe purpose of this study was to determine the efficacy and safety of flow diversion technology in the treatment of aneurysms of carotid-ophthalmic aneurysms.Materials and methodsThis study retrospectively reviewed outcomes...

Pattern of serum cardiac troponin-I in symptomatic acute myocardial infarction patients in national institute of cardiovascular disease in Bangladesh

Troponin I (cTnI) isoform is cardiac muscle specific protein and shown to have several features as a preferred marker of myocardial injury. It rises early in acute myocardial infarction (AMI) and attains levels that are clearly separated from baseline values. It remains elevated for several days providing a long window for detection of cardiac injury. The objective of the study was to evaluate for the profile of cTnI level among symptomatic AMI patients. The study was conducted at National Institute of Cardiovascular Disease, Dhaka, Bangladesh from July 2007 to June 2008 and total 9552 patients with type 1 or type 2 MI were included. Blood Sample was taken within 3 days of symptoms and cTnI was measured by chemiluminescent immunometric assay method. cTnI was considered positive when the value was &gt;1ng/ml and study population was divided as per age, sex and cTnI level. The mean (+ SD) age of all patients was 55(+ 12.8) years and majority was males (82.20%). Seasonal variation showed highest positive cases in winter. In case of circadian variation positive cTnI results were suggestive of morning peak of AMI. Positive results were obtained in 32.3% of Cases. cTnI is now considered as a better indicator of myocardial injury. Further study in depth is necessary to correlate with clinical symptoms and other diagnostic tests to make a complete profile of AMI according to the latest subtypes. DOI: http://dx.doi.org/10.3329/bmj.v42i1.18969 Bangladesh Med J. 2013 Jan; 42 (1): 3-6

The risk of venous thromboembolism, myocardial infarction, stroke, major bleeding and death in patients undergoing total hip and knee replacement

We examined the risk of thrombotic and major bleeding events in patients undergoing total hip and knee replacement (THR and TKR) treated with thromboprophylaxis, using nationwide population-based databases. We identified 83 756 primary procedures performed between 1997 and 2011. The outcomes were symptomatic venous thromboembolism (VTE), myocardial infarction (MI), stroke, death and major bleeding requiring hospitalisation within 90 days of surgery. A total of 1114 (1.3%) and 483 (0.6%) patients experienced VTE and bleeding, respectively. The annual risk of VTE varied between 0.9% and 1.6%, and of bleeding between 0.4% and 0.8%. The risk of VTE and bleeding was unchanged over a 15-year period. A total of 0.7% of patients died within 90 days, with a decrease from 1% in 1997 to 0.6% in 2011 (p < 0.001). A high level of comorbidity and general anaesthesia were strong risk factors for both VTE and bleeding, with no difference between THR and TKR patients. The risk of both MI and stroke was 0.5%, which remained unchanged during the study period. In this cohort study of patients undergoing THR and TKR patients in routine clinical practice, approximately 3% experienced VTE, MI, stroke or bleeding. These risks did not decline during the 15-year study period, but the risk of dying fell substantially.

Cerebral Microbleeds and Asymptomatic Cerebral Infarctions in Patients with Atrial Fibrillation

Atrial fibrillation (AF) is a cardiac arrhythmia that does not infrequently induce ischemic strokes; however, little research has been reported on focal cerebral microangiopathic lesions in patients with AF. Recently cerebral microbleeds (CMBs) have been noticed for their potential implication in cerebral small vessel disease. Therefore, we had 2 goals in the present study: (1) to compare the prevalence of CMBs in patients with AF with that in patients without AF, and (2) to prove that CMBs could be a clinical predictive factor for the development of future cerebral microangiopathy in patients with AF without a history of symptomatic cerebral infarction in a prospective manner. We performed yearly brain magnetic resonance imaging (MRI) assessments for a maximum of 5 years in 131 patients with AF and 112 control patients. Seventy-seven patients with AF underwent more than 3 yearly MRI scans. The Kaplan-Meier curve showed that the development of an asymptomatic cerebral infarction (ACI) was associated with the baseline presence of a CMB (P=.004). A multivariate Cox regression analysis revealed that the CMBs at baseline were significantly associated with an increment in not only the occurrence of ACIs (hazard ratio [HR], 5.414; 95% confidence interval [CI], 1.03-28.43; P=.046) but also in the consecutive development of CMBs (HR, 6.274; 95% CI, 1.43-27.56; P=.015). Patients with AF had a significantly higher prevalence of CMBs. The presence of CMBs in the baseline MRI may predict the consequent onset of an ACI and increase in CMBs in patients with AF.

Pineal calcification is a novel risk factor for symptomatic intracerebral hemorrhage

BackgroundPineal calcification is associated with symptomatic cerebral infarction in humans. However, there are limited data on the association of pineal calcification and intracerebral hemorrhage. We evaluated this association of symptomatic intracerebral hemorrhage and pineal calcification by computed tomography of the brain. MethodsWe reviewed all computed tomographic (CT) scans of the brains of patients over 15 years of age during the year 2011 at a university teaching hospital. Symptomatic intracerebral hemorrhage was identified by having clinical syndrome of stroke and acute intracerebral hemorrhage from brain CT scans. Pineal calcification was also evidenced by brain CT scans. Other stroke risk factors were recorded. The association of various risk factors including pineal calcification and intracerebral hemorrhage was calculated using logistic regression analysis. ResultsThere were 2140 CT scans of the brains during the study period. Of those, 1071 scans (50.05%) met the study criteria. Intracerebral hemorrhage and pineal calcification were found in 77 (7.2%) and 689 (64.3%) patients, respectively. Pineal calcification was a significant risk factor for intracerebral hemorrhage with an adjusted odds ratio of 2.36 (95% confidence interval of 1.22-4.54). Other significant factors were age>50 years, hypertension, and diabetes. ConclusionPineal calcification is associated with symptomatic intracerebral hemorrhage.

PT221 Nocturnal hypertension is associated with preclinical organ damage in untreated hypertension

Introduction: Stroke related with catheterization was devastating complications after procedures. The rates of stroke range from 0.1-0.4% according to previous studies. Stroke was taken only as new neurological complications, therefore clinically unapparent cerebral embolisms were not taken into account. Diffusion weighted magnetic resonance imaging (DW-MRI) is very high sensitive tools for detecting acute cerebral ischemic lesions. Due to improvements of catheter design and approach, catheterization-related cerebral infarctions are expected to decrease, whereas this may be counterbalanced by increased risk profile of patients who undergo catheterization. Objectives: We aimed to examine the current prevalence and risk factors of symptomatic and asymptomatic catheterization-related cerebral infarctions by DW-MRI. Methods: We retrospectively analyzed 84 patients who underwent 1237 diagnostic and interventional catheterization procedures through the aortic arch conducted within 2010 and 2011 in our hospital and who obtained the MRI within 14 days a catheterization. Results: Ten patients who developed symptoms and 3 patients were finally diagnosed as stroke, which was defined as any neurological deficits lasting over 24 hours. The remaining 74 patients were asymptomatic and underwent MRI for various other reasons, including the assessment before coronary artery bypass graft (35%), valvular surgery (18%) or aortic repair (6.8%). The MRI revealed a fresh cerebral infarction in 22 of 74 asymptomatic patients (29.7%). Patients with cerebral infarction underwent longer procedures (mean SEM, 17.1 1.7 minutes vs. 22.7 2.4 minutes, p<0.05), used higher number of catheters and were more likely to be old (mean SEM, 74.1 1.67 vs. 70.4 1.1 years old), to have dyslipidemia, and to undergo in urgent settings and for interventional purposes. In DW-MRI findings, more patients with new infarction had multiple or bilateral lesions. More lesions were seen in the anterior and anterior plus posterior territories. Conclusion: Stroke after catheterization occurred 3 of 1237 (0.16%) patients, and this rate was almost equivalent to those seen in previous studies. However, the rate of small asymptomatic catheterization-related cerebral infarctions detected using diffusion-weighted MRI remains high in high-risk patients or candidates for cardiac surgery. Disclosure of Interest: None Declared