Artery Territory Research Articles

SURGICAL CHALLENGES IN CLIPPING LARGE ANEURYSMS IN DISTAL ARTERIAL TERRITORIES

Background By distal arterial territories we mean the arteries located after the main bifurcations of the cerebral arteries. They can occur at multiple sites throughout the course of distal arteries, but most often are found after the bifurcation of the M1 segment of the middle cerebral artery. Methods A retrospective review of 18 consecutive patients with large aneurysms located in distal arterial territories, treated by surgical clipping between 2019-2023, was performed. We consider aneurysm larger than 10 mm in diameter as large aneurysm. The data of all our consecutive patients were searched to obtain patient characteristics, details of the aneurysm size and orientation, treatment details, complications and follow up. At admission, the clinical condition of all patients was classified according to the Hunt and Hess scale. Clinical outcome was graded according to the modified Rankin scale. The follow-up period varied widely from 6 to 54 months (mean 24 months). Results Surgical clipping was performed for all aneurysms; only in 2 cases the aneurysm was unruptured. Three patients presented with significant hematoma which required the evacuation of the clot. Most large aneurysms were located in M2 or M3 segments of the MCA (16 patients). Post-operative control angiography was performed in 11 patients (61%), from which we reported a full occlusion of the aneurysm in 10 patients (90%). No perioperative mortality was recorded. The outcome was graded mRankin 0–2 in 83% of the cases (15 patients) at the end of the first postoperative months, and 94.4% (17 patients) at six months follow-up. The most important improvement was recorded for patients graded mRankin 1-2 at the first month follow-up. Conclusions The large size of the aneurysm, the size of the neck, as well as the reduced diameter of the parent vessel, represent important trials for the neurosurgeon in the correct clipping of the aneurysm. In some cases, sectioning of the aneurysm dome was necessary for successful clipping.

Microvascular resistance reserve in relation to total and vessel-specific atherosclerotic burden.

The relationship between coronary artery atherosclerosis and microvascular resistance remains unclear. This study aims to clarify the relationship between total atherosclerotic and vessel-specific atherosclerotic burden and microvascular resistance reserve (MRR). In this post-hoc analysis of the PACIFIC 1 trial, symptomatic patients without prior coronary artery disease (CAD) underwent [15O]H2O positron emission tomography, coronary computed tomography angiography (CCTA) and invasive fractional flow reserve (FFR). MRR was assessed across all three coronary branches, utilizing PET-derived coronary flow reserve and invasive FFR measurements. CCTA was used to assess patient and vessel-specific plaque volumes. Percentage atheroma volume (PAV) was defined as total plaque volume divided by vessel volume. The study included 142 patients (55% male, 57.5±8.6 years) with 426 vessels with a mean MRR of 3.77±1.64. While a significantly higher PAV was observed in the left anterior descending artery territory, MRR was similar across the three coronary branches. Generalized Estimating Equations without correction for cardiovascular risk factors identified that patient-specific PAV tertiles but not vessel-specific PAV tertiles were related to vessel-specific MRR. After correction for cardiovascular risk factors, compared to the first tertile of patient-specific PAV, the second tertile showed a vessel-specific MRR decrease of β=-0.362, p=0.018, and the third tertile showed a decrease of β=-0.347, p=0.024. In patients without prior CAD, patient-specific plaque burden was negatively associated to vessel-specific MRR; however, vessel-specific plaque burden was not related to vessel-specific MRR. Our findings suggest that the relation between atherosclerotic burden and an impaired microcirculatory function is of systemic origin.

Long-Term Neurologic Outcomes in Pediatric Arterial Ischemic Stroke: The Impact of Age and Lesion Location.

The impact of age-at-stroke on outcome following pediatric arterial ischemic stroke remains controversial. We studied the interaction of age-at-stroke and infarct location and extent with long-term neurological outcomes. We conducted a longitudinal prospective outcome study of children with acute pediatric arterial ischemic stroke diagnosed from 1996 to 2016 at the Hospital for Sick Children, Toronto, Canada. Pediatric Stroke Outcome Measure scores were dichotomized as normal or abnormal (ie, mild, moderate, or severe). Outcomes were analyzed by age-at-stroke (newborn: birth to 28 days; early childhood: 29 days to 5 years; middle/late childhood: >5-18 years), and infarct location, based on each of the following: model 1: circulation (anterior/posterior); model 2: cortical versus subcortical involvement; and model 3: specific arterial territory, including infarct extent (small [<50% arterial territory] or large [≥50%]). Univariable and multivariable logistic regression models were fitted. Among 285 children, the outcome at median 6.1 years was 43.5% abnormal. Controlling for infarct location, increasing age-at-stroke was associated with increasing abnormal outcome. Model 1 demonstrated that, compared with neonates, abnormal outcomes were increased in early childhood (adjusted odds ratio [aOR], 2.91 [95% CI, 1.24-7.05]) and more so in middle/late childhood (aOR, 4.46 [95% CI, 1.71-12.13]). Outcomes were worse for combined locations, including anterior+posterior (model 1: aOR, 15.4 [95% CI, 4.49-64.63]) and cortical+subcortical (model 2: aOR, 10.7 [95% CI, 3.88-32.74]). Abnormal outcomes were also increased for anterior circulation (model 1: aOR, 14.91 [95% CI, 5.29-54.21]) and subcortical locations (model 2: aOR, 4.36 [95% CI, 1.37-14.95]). Among individual arterial territories, outcomes were best for superior division middle cerebral artery (100% normal) and worst for lateral lenticulostriate artery infarcts (47.4% abnormal; model 3: aOR, 14.2 [95% CI, 3.5-67.6]). Among survivors of pediatric stroke, abnormal long-term neurological outcome is increased with increasing age-at-stroke, supporting enhanced plasticity after focal injury to the newborn brain compared with older pediatric ages.

Associations of smoking status with long-term cardiovascular events in different arterial territories: the EPIC Norfolk prospective population cohort

Abstract Background Smoking cessation is associated with a reduced risk of cardiovascular disease (CVD) events, mainly in ischemic heart disease (IHD) and stroke. However, the impact of smoking status (never, former or current smoking) on long-term CVD events across different arterial territories remains understudied. Knowledge of such associations is important, as it may assist in risk communication and smoking cessation motivation. We therefore investigated associations between smoking status and territory-specific CVD events in a large cohort with ≥20 years follow-up. Methods We included participants without baseline CVD from the European Prospective Investigation of Cancer (EPIC) Norfolk prospective population cohort. The strengths of associations between smoking, former smoking and never smoking with the first occurrence of a CVD event were evaluated using a competing risk-adjusted regression model. CVD events were defined as hospitalisation or death due to IHD, ischemic stroke, haemorrhagic stroke, peripheral arterial disease (PAD) or aortic aneurysm (AA). Patients were followed-up until the first event, non-CVD death (competing risk) or end of study (15-03-2018). The model was adjusted for sex, age, systolic blood pressure, low-density lipoprotein cholesterol (LDL-c), high-density lipoprotein cholesterol (HDL-c), diabetes, renal function and body mass index. We compared former and current smoking (at baseline) with never smoking. Results We included 23,581 participants (56% women) with a median baseline age of 58 years [interquartile range (IQR) 51-66]. During median follow up of 21.3 years (IQR 19.0-22.8), 26.4% experienced ≥1 CVD event. The first event of occurrence was IHD in 17.3%, ischemic stroke in 3.6%, haemorrhagic stroke in 1.4%, PAD in 3.1% and AA in 1.4%. Current (vs. never) smoking was associated with IHD [adjusted hazard rate (aHR) 1.53, 95% confidence interval (CI) 1.36-1.72], PAD (aHR 1.29, 95%CI 1.07-1.56) and AA (aHR 4.81, 95%CI 3.54-6.54). Current smoking was not significantly associated with ischemic stroke (aHR 1.20, 95% CI 0.95-1.52) and haemorrhagic stroke (aHR 1.18, 95% CI 0.81-1.70). In former (vs. never) smoking individuals, the association with AA remained statistically significant but less pronounced [aHR 1.69, 95%CI 1.29-2.23]. Conversely, former smoking was not associated with IHD (aHR 1.07, 95%CI 0.99-1.16) or PAD (aHR 1.09, 95%CI 0.95-1.26) (Figure 1). Conclusion After 20-years of follow-up, former smokers, compared to never-smokers, remain at considerably higher risk for CVD events, particularly for aortic aneurysm. This knowledge may assist in treatment decisions and risk communication.

Screening for subclinical atherosclerosis in patients clinically diagnosed with familial hypercholesterolemia and determination of imaging-guided patient management strategy

Abstract Introduction Familial hypercholesterolemia (FH) is a monogenic dyslipidemia characterized by elevated plasma LDL-C levels, leading to early cardiovascular disease. The Dutch Lipid Clinic Network (DLCN) score is the most widely used clinical scoring system in current practice. Subclinical atherosclerosis is defined as the detection of atheromatous plaques in arterial territories, such as coronary, carotid or iliofemoral, before a symptom or event occurs. It is an early indicator of atherosclerotic burden. In this study, we investigated the presence of subclinical atherosclerosis in FH patients with a definite or probable clinical diagnosis according to DLCN score. We also tried to identify independent predictors of subclinical atherosclerosis. Methods This study is a single-center, prospective, and cross-sectional investigation involving a cohort of 215 FH patients. These patients are primary prevention patients and among them, 120 patients received a definite clinical diagnosis, while 95 patients received a probable clinical diagnosis based on the DLCN score. Carotid USG and Femoral USG were performed to screen for subclinical atherosclerosis and CAC score was calculated by non-contrast CT. Apo A-I, Apo B and Lp (a) measurements were analyzed by immunonephelometric method. Results The study population consisted of 136 (63%) women and 79 (37%) men. The mean age was 54 years (43-62) and the stigmata rate was 18%. Initially, 17% of patients were on aspirin, and 32% were receiving statin treatment; however, following subclinical atherosclerosis screening, these proportions significantly increased (aspirin usage to %32 and statin usage to %96) within the population. 148 patients (69%) had subclinical atherosclerosis in at least one site. Upon regional analysis, subclinical atherosclerosis rates were 48% in the coronary arteries, 47.5% in the carotid bifurcation region, and 40.5% in the femoral bifurcation region. Additionally, 25% of patients had atherosclerosis at one site, 27% at two sites, and 17% at all three sites. Age, male gender, pretreatment LDL-C level, Apo A-I/Apo B ratio and DM were identified as independent predictors of the presence of subclinical atherosclerosis in the FH patients. Furthermore age, male gender, pretreatment nonHDL-C level, Lp (a) ≥ 30 mg/dl and presence of femoral plaque were identified as independent predictors of coronary atherosclerosis. Conclusion Subclinical atherosclerosis is prevalent among FH patients, and this study has identified independent predictors associated with presence of subclinical atherosclerosis. However, despite this heightened risk, medication utilization among these patients remains below optimal levels and only a small proportion of the population has achieved their treatment goals. Our study highlights the influence of subclinical atherosclerosis on treatment approaches, as demonstrated by the notable rise in statin and aspirin utilization observed after screening.Clinical and biochemical characteristicsSubclinical Atherosclerosis Rates

Heterogeneous associations of traditional atherosclerotic risk factors and long-term events in different arterial territories: the EPIC Norfolk prospective population cohort

Abstract Background Atherosclerotic risk factors have been associated with cardiovascular disease (CVD) events in specific arterial territories. However, these observations are limited by relatively short-term follow-up (i.e. ten years) and a focus on a limited number of outcome events. We therefore investigated associations between atherosclerotic risk factors and territory-specific cardiovascular events in a large cohort with ≥20 years follow-up. Methods We included participants without baseline CVD from the European Prospective Investigation of Cancer (EPIC) Norfolk prospective population cohort. The strengths of associations between CVD risk factors (smoking, low-density lipoprotein cholesterol (LDL-c), and systolic blood pressure (SBP)) and the first occurrence of a CVD event were evaluated using a competing risk-adjusted regression model. CVD events were defined as hospitalisations or death due to ischemic heart disease (IHD), ischemic stroke, haemorrhagic stroke, peripheral arterial disease (PAD) or aortic aneurysm (AA). Patients were followed-up until the first event, non-CVD death (competing risk) or end of study (15-03-2018). The model was adjusted for sex, age, diabetes, HDL-c, kidney function and body mass index. LDL-c and SBP were analysed by comparing highest versus lowest quartiles. Smoking (at baseline) was compared to never smoking. Results We included 23,581 participants (56% women) with a median baseline age of 58 years [interquartile range (IQR) 51-66]. During median follow up of 21.3 years (IQR 19.0-22.8), 26.4% of individuals experienced ≥1 CVD event. The first event of occurrence was IHD in 17.3%, ischemic stroke in 3.6%, haemorrhagic stroke in 1.4%, PAD in 3.1% and AA in 1.4%. LDL-c was strongest associated with IHD [adjusted hazard rate (aHR) 1.7, 95% confidence interval (CI) 1.5-1.9], SBP with ischemic stroke (aHR 1.9, 95%CI 1.5-2.5) and smoking with AA (aHR 4.8, 95%CI 3.5-6.5) (Figure 1). Conclusions There is considerable heterogeneity in the associations between atherosclerotic risk factors and long-term, first, territory-specific cardiovascular events. Knowledge of these differences may assist in personalised treatment decisions and risk communication.

Long-term survival after coronary artery bypass grafting comparing bilateral versus single internal mammary artery in a women cohort

Abstract Introduction Although neutral results from the ART randomized controlled trial, observational studies have been supporting better survival after bilateral internal mammary artery (BIMA) vs single internal mammary artery (SIMA) coronary artery bypass grafting (CABG). However, for some specific subgroups, like women patients, more doubts remain about BIMA benefits. Aim To compare long-term survival and early results in women after SIMA vs BIMA. Methods Longitudinal, retrospective, single-center study including consecutive women with at least 2 left-coronary system (LCS) vessel disease who underwent primary isolated CABG with at least 1 internal mammary artery (IMA) conduit and a minimum of 2 conduits targeting the LCS, between 2004-2014. Emergent or salvage surgeries, on-pump beating-heart, BIMA in which 1 IMA targeted the right coronary artery territory were excluded. The primary outcome was all-causes mortality (checked on February 2023). Time-to-event outcomes were studied using Kaplan-Meier Curves, Log-Rank test and multivariable Cox Regression. Median follow-up was 11 years, maximum of 19 years. Results From 539 women selected for this study, BIMA CABG was performed in 30%. SIMA patient’s were older (mean age 68.95±8.39 vs 62.75±9.82 years, p&amp;lt;0.001), but the prevalence of cardiovascular risk factors were similar between groups (arterial hypertension, p=0.693; dyslipidemia, p=0.111; diabetes mellitus, p=0.462 and obesity, p=0.109). Peripheral artery disease (p=0.707), left ventricular dysfunction (p=0.727), cerebrovascular disease (p=0.730), active smoking habits (p=0.05) and chronic obstrutive pulmonary disease (p=0.537) were also similar. Severe chronic kidney disease (27% vs 14%, p&amp;lt;0.001) and Canadian Coronary Society - grade IV (74% vs 63%, p=0.011) were more frequent in SIMA group. In the univariable survival analysis, SIMA had worse survival results than BIMA (Log Rank test p&amp;lt;0.01). At 5-, 10- and 15- years of follow-up, cumulative survival for SIMA vs BIMA were 88% vs 90%, 68% vs 75%, 42% vs 58%, respectively. However, the multivariable Cox regression showed that BIMA was not associated with long-term survival (HR [95%CI]: 1.09 [0.75-1.59], p=0.6). Most of post-operative outcomes were similar between groups, with the exception of atrial fibrilation (25% vs 16%, p=0.031) and time to discharge (median days [min-max]: 7 [4-128] vs 7 [4-59]) that were higher in SIMA. No differences were found in immediate reexploration of thorax (sternal infection – 0.3% SIMA vs 1.2% BIMA, p=0.219; bleeding- 1.6% SIMA vs 0.6% BIMA, p=0.681). Redo CABG occurred in 1 SIMA and 1 BIMA women, at 41 and 84 months of follow-up, respectively. Conclusion In this study, revascularization with BIMA seems to be safe in women and provides similar results than SIMA. More studies in women are needed to establish the better approach for this specific subgroup.

The impact of QRS complex fragmentation status before and after cardiac resynchronization therapy with defibrillator implantation: Is it a predictor of arrhythmic events?

Abstract Introduction Cardiac resynchronization therapy with an implantable cardioverter defibrillator (CRT-D) has demonstrated efficacy in reducing mortality, hospitalization for heart failure (HF), and sudden cardiac death among subgroups of patients with HF with reduced ejection fraction (HFrEF). However, this population is highly heterogeneous, necessitating risk stratification. Several clinical findings, including QRS complex fragmentation (QRSf), have been identified as potential prognostic factors for arrhythmic risk. Nonetheless, evidence supporting the prognostic significance of QRSf in patients undergoing CRT-D remains limited. Purpose The aim of this study is to assess whether alterations in QRSf status, before and after CRT-D implantation, can predict arrhythmic events (AE) in patients with HFrEF. Methods This study included consecutive patients underwent CRT-D implantation at our center from October 2009 to December 2022. Demographic, clinical, electrocardiographic and echocardiographic data were obtained from electronic medical records and telephone interviews. QRSf was defined by the presence of various RSR′ patterns, including additional R waves (R′) or notching of the R and S wave in two contiguous leads corresponding to a primary coronary artery territory on a 12-lead electrocardiogram conducted before and after CRT-D implantation. An AE was characterized by appropriate ICD therapy (antitachycardia pacing or shock) for a ventricular arrhythmia or sustained ventricular arrhythmia without the need for ICD therapy. Results A total of 176 patients were included (mean age 69.9 ± 9.6 years with 80.6% male). Ischemic etiology accounted for 54.6% of cases of LV systolic dysfunction, with a mean baseline LVEF of 23.6%. CRT-D was indicated as secondary prevention in 18 patients. At baseline, 114 patients (64.8%) presented QRSf. Following CRT implantation, 17 patients (9.8%) without previous QRSf developed QRSf, while 26 patients (14.9%) resolved QRSf. The median follow-up was 43.6 months (interquartile range 19.5-81.1). During follow-up, 90 patients died and 29 AE occurred (16.5%). Among these, 23 patients had QRSf before and after CRT, whereas 6 AE occurred in patients without QRSf. Multivariate survival analysis using Cox regression demonstrated that the presence of QRSf before and after CRT-D was an independent predictor of AE (HR 3.56; 95% CI 1.00-12.70). Univariate and multivariate Cox regression analyses are presented in Table 1. Kaplan-Meier curves for AE in relation to QRSf status before and after CRT-D are illustrated in Figure 1. Conclusions Our findings suggest that the presence of QRSf and its persistence following CRT-D implantation appears to be an independent predictor of AE after CRT-D implantation in patients with HFrEF. Therefore, these patients would benefit from closer monitoring as they exhibit a heightened risk of arrhythmic events. Nevertheless, further research is warranted to validate these results.Table 1.Cox Regression Analysis.

Impact of QRS complex fragmentation on all-cause mortality before and after cardiac resynchronization therapy

Abstract Introduction Cardiac resynchronization therapy (CRT) have demonstrated to reduce all-cause mortality in selected patients with HFrEF. However, there is still a high rate of non-responders, so risk stratification is crucial. Fragmentation of the QRS complex (QRSf) has been suggested as a valuable prognostic factor in different cardiac diseases, but the evidence in patients undergoing CRT is controversial and limited. Purpose To evaluate if changes in QRSf status before and after CRT implantation has a prognostic role in patients undergoing CRT in terms all-cause mortality. Methods Consecutive patients undergoing CRT were prospectively included from October 2009 to December 2022. Demographic clinical, electrocardiographic and echocardiographic variables were recorded. Prospective follow-up variables were collected from electronic clinical records and telephone interview. QRSf complex was defined by the presence of different RSR′ patterns including additional R-waves (R′) and notches of the R-wave and S-wave in two contiguous leads corresponding to a main coronary artery territory in a 12-lead electrocardiogram performed before and after CRT. Results A total of 244 patients (mean age 71.8 ± 9.8 years, 79.5% male) were included. The etiology of LV systolic disfunction was ischemic in 50.0%. Mean LVEF before implantation was 25 ± 9%. A CRT-D was implanted in 176 patients (72.2%). The mean width of the paced QRS was 141 ± 23 ms. At baseline, 150 patients had a QRSf. After CRT implantation, 69 (28.4%) patients experimented a change in QRSf status: 29 patients (11.9%) without prior QRSf developed QRSf, whereas 40 patients (16.5%) resolved QRSf after CRT. Median follow-up time was 36.0 months (interquartile range 18.2-75.7). During the follow-up period, 90 patients died. In the multivariate Cox regression survival analysis, the presence of QRSf before the implantation with or without paced QRSf after CRT were independently associated with all-cause mortality (HR 4.43; 95% CI 1.53-12.80 and HR 3.69; 95% CI 1.16-11.80 respectively). Those without QRSf prior implantation who developed QRSf after CRT did not present significantly higher risk of all-cause mortality. Univariate and multivariate Cox regression analyses for all-cause mortality are presented in Table 1. Figure 1 presents Kaplan-Meier curves for all-cause mortality according to QRSf status before and after CRT implantation. Conclusions According to our results, preimplantation QRSf is an independent predictor of all-cause mortality regardless the resolution or maintenance of QRSf after CRT in patients with HFrEF undergoing CRT. Therefore, patients with QRSf before CRT implantation regardless the paced QRSf status, should be followed more strictly because they are at higher mortality risk.Table 1.Cox Regression Analyses

QRS complex fragmentation status before and after cardiac resynchronization therapy predicts hospitalizations for heart failure

Abstract Introduction Cardiac resynchronization therapy (CRT) reduces mortality and hospitalization for heart failure (HF) in selected patients with HF with reduced ejection fraction (HFrEF). However, there is a significant percentage of non-responders who are readmitted for HF after implantation. Several biomarkers and electrocardiographic findings have been suggested as prognostic markers in this group of patients. Fragmentation of the QRS complex (QRSf) has been associated with worse prognosis in several cardiac diseases, but evidence in patients undergoing CRT remains to be limited. Purpose To evaluate if the changes in QRSf status before and after CRT implantation have a prognostic role in patients undergoing CRT in terms of hospitalization for HF. Methods Consecutive patients undergoing CRT were prospectively included from October 2009 to December 2022. Demographic clinical, electrocardiographic and echocardiographic variables were recorded. Prospective follow-up variables were collected from electronic clinical records and telephone interview. QRSf complex was defined by the presence of different RSR′ patterns including an additional R-waves (R′) and notches of the R-wave and S-wave in two contiguous leads corresponding to a main coronary artery territory in a 12-lead surface electrocardiogram performed before and after CRT. Results A total of 244 patients (mean age 72 ± 10 years, 80% male) were included. The etiology of the LV systolic dysfunction was ischemic in 50.0%. Mean LVEF before implantation was 25 ± 9% and mean paced QRS width was 141 ± 23 ms. CRT-D was implanted in 176 patients (72.2%). At baseline, 150 patients had a QRSf. After CRT implantation, 69 (28.4%) patients experimented a change in QRSf status: 29 patients (11.9%) without prior QRSf developed QRSf, whereas 40 patients (16.5%) resolved QRSf after CRT. Median follow-up time was 36.0 months (interquartile range 18.2-75.7). At follow-up, 90 patients died and 91 presented at least one hospitalization for HF. Multivariate Cox regression survival analysis showed that development of QRSf after CRT implantation (HR 8.87; 95% CI 1.85-42.50) and the presence of QRSf before implantation with or without paced QRSf after CRT (HR 8.21; 95% CI 1.75-38.50 and HR 16.70; 95% CI 3.88-71.80 respectively) were independently associated with hospitalizations for HF. Univariate and multivariate Cox regression analyses for HF hospitalization are presented in Table 1. Figure 1 presents Kaplan-Meier curves for QRSf status and hospitalizations for HF. Conclusions According to our results, QRSf status before and after CRT have a significant prognostic role in terms of hospitalization for HF after CRT, especially in those who develop QRSf after CRT and those with baseline QRSf regardless QRSf status after CRT. The worse prognosis was observed in those with QRSf before and after CRT. Therefore, these patients should be followed more strictly because they are at higher risk of decompensation.Table 1.Cox Regression Analyses

PERFIL DOS RESULTADOS DE ESCORE DE CÁLCIO DE CORONÁRIAS EM UM SERVIÇO PRIVADO DE ARACAJU

INTRODUCTION: Cardiovascular diseases (CVD) are responsible for one third of all deaths worldwide, with immutable risk factors such as age and gender, but also mutable factors such as sedentary lifestyles, obesity, hypertension and alcohol consumption. Given this scenario, there is a need to stratify the risk of individuals. The Coronary Calcium Score (CCS) is a tool used in non-contrast CT scans to stratify cardiovascular risk by quantifying the amount of calcium in the coronary arteries. OBJECTIVE: To analyze the coronary calcium score profile of patients at a private service in Aracaju/SE. METHODS: This is a quantitative, cross-sectional, documentary, descriptive and retrospective study, produced by evaluating tomography reports for calcium score, performed on outpatients, in a private service in Aracaju-SE, between January 1 and December 31, 2023. A total of 227 examination reports were obtained. The inclusion criteria were imaging reports from January to December 2023. Duplicate exams, exams of other areas of the body and exams outside the period listed for the research were excluded. RESULTS: Our sample consisted of 125 women and 102 men, with no difference in mean age between them, whose mean calcification was 215.46. Men had higher overall mean values for calcium score and calcification volume than women, as well as for the arterial territories (DA, CX and CD), with the exception of the TCE, for which there was no difference between the genders. CONCLUSION: These data reveal a higher proportion of women undergoing examinations compared to men. Although most of the individuals in the study did not have significant coronary calcification, it was observed that, among the cases of significant calcification, men were more affected than women.

Redefining Infarction Size for Small-Vessel Occlusion in Acute Ischemic Stroke: A Retrospective Case-Control Study.

Small-vessel occlusion, previously referred to as lacunar infarcts, accounts for approximately one-third of all ischemic strokes, using an axial diameter of less than 20 mm on diffusion-weighted imaging. However, this threshold may not adequately differentiate small-vessel occlusion from other pathologies, such as branch atheromatous disease (BAD) and embolism. This study aimed to assess the clinical significance and pathological implications of acute small subcortical infarctions (SSIs) based on infarct diameter. We conducted a retrospective case-control study using data from stroke patients recorded between 2016 and 2021 of the Stroke Registry in Chang Gung Healthcare System. Patients with acute SSIs in penetrating artery territories were included. Key variables such as patient demographics, stroke severity, and medical history were collected. Infarcts were categorized based on size, and the presence of early neurological deterioration (END) and favorable functional outcomes were assessed. Among the 855 patients with acute SSIs, the median age was 70 years and the median National Institutes of Health Stroke Scale (NIHSS) score at arrival was four. END occurred in 97 patients (11.3%). Those who experienced END were significantly less likely to achieve a favorable functional outcome compared to those who did not (18.6% vs. 59.9%, p < 0.001). The incidence of END increased progressively with infarct sizes of 15 mm or larger, with the optimal threshold for predicting END identified as 15.5 mm and for BAD, it was 12.1 mm. A multiple logistic regression analysis revealed that motor tract involvement [adjusted odds ratio (aOR) 2.3; 95% confidence interval (CI) 1.1-4.7], an initial heart rate greater than 90 beats per minute (aOR 2.3; 95% CI 1.2-4.3), and a larger infarct size (15 mm to less than 20 mm vs. 10 mm to less than 15 mm; aOR 3.0; 95% CI 1.4-6.3) were significantly associated with END. Our findings suggest that setting the upper limit for small-vessel occlusion at 15 mm would be more effective in distinguishing it from BAD. However, these findings should be interpreted in the context of the retrospective design and study population. Further multi-center research utilizing high-resolution vessel wall imaging is necessary to refine this threshold and enhance diagnostic accuracy.

Cerebral ptosis: An ominous sign in stroke—A retrospective study

AbstractIntroductionCerebral ptosis is defined as the drooping of eyelids due to lesions in the cerebral hemispheres. Cerebral ptosis is due to either unilateral or bilateral hemispheric damage without brainstem involvement. Ischemic strokes are the most common etiology leading to hemispheric damage.AimsTo assess the prevalence of cerebral ptosis in ischemic strokes and to correlate the presence of cerebral ptosis with the outcome of the patients. To also assess the demographic profile of these patients.Materials and MethodsThis is a retrospective study from June 2022 to August 2024. All patients diagnosed as acute stroke presenting with cerebral ptosis within day 3 of stroke were included. Patients with a reduced level of consciousness, brainstem involvement, and those with signs of impending herniation were excluded. The modified Rankin scale (mRS) on the day of admission and the day of discharge were compared.ResultsThere were 26 patients with cerebral ptosis among 649 patients admitted with anterior circulation stroke (prevalence 4.01%). 84.6% (n = 12) had right hemisphere involvement and 15.4% (n = 4) had left side involvement. 88.5% (n− = 23) had middle cerebral artery territory involvement and 7.7% (n = 2) had internal carotid artery territory involvement. The mean mRS on admission was 4.42 and 4.81 on discharge (paired t‐test 0.015). mRS 6 (death) was observed in four patients.ConclusionCerebral ptosis is a supranuclear disorder with the most common etiology being vascular insult to the cerebral hemisphere. It is an ominous and rare clinical sign. Identification of this entity is important, and it is not to be confused with a reduced level of consciousness.

More severe cerebral small vessel disease associated with poor leptomeningeal collaterals in symptomatic intracranial atherosclerotic stenosis.

We investigated the association between cerebral small vessel disease (CSVD) and ipsilateral leptomeningeal collateral (LMC) status in patients with symptomatic intracranial atherosclerotic stenosis (sICAS). In 108 patients with 50-99% symptomatic intracranial internal carotid artery or M1 middle cerebral artery stenosis, 4 CSVD imaging markers (lacunes, cerebral microbleeds, enlarged perivascular spaces [EPVSs], and white matter hyperintensities [WMHs]) were assessed in MRI. Score of 0 or 1 was assigned to each marker and added up as a summary CSVD score (ranging 0-4) to reflect an overall CSVD burden. Ipsilateral LMC status was assessed by determining the laterality of distal vessels in anterior and posterior cerebral artery territories on CT angiography. Moderate-to-severe EPVSs (adjusted odds ratio [aOR] = 4.15; p = 0.031) and WMHs (aOR = 5.90; p = 0.010), and higher summary CSVD score (aOR = 1.66; p = 0.030) were independently associated with poor LMCs. There was significant interaction between stenosis percentage in sICAS and summary CSVD score on poor LMCs (p = 0.022 for interaction), when higher CSVD score was significantly associated with poor LMCs in patients with severe sICAS (aOR = 2.84; p = 0.011) but not in those with moderate sICAS. The findings indicated possibly adverse effect of CSVD on the recruitment or development of LMCs in sICAS patients, especially in patients with severe sICAS.

18F-NaF uptake on vascular PET imaging in symptomatic versus asymptomatic atherosclerotic disease: A meta-analysis.

18F-sodium fluoride (NaF) positron-emission tomography (PET) is increasingly being used to measure microcalcification in atherosclerotic disease in vivo. Correlations have been drawn between sodium fluoride uptake and the presence of high-risk plaque features, as well as its association with clinical atherosclerotic sequelae. The aim of this study was to perform a meta-analysis of NaF uptake on PET imaging and its relation to symptomatic and asymptomatic disease. A systematic review was performed according to PRISMA guidelines, via searching the Ovid MEDLINE, Ovid Embase, Cochrane Library, PubMed, Scopus, and Web of Science Core Collection databases up to May 2024. The search strategy included the terms 'NaF', 'PET', and 'plaque', and all studies with data regarding the degree of microcalcification, as measured by 18F-NaF uptake in symptomatic and asymptomatic atherosclerotic plaques, were included. Analysis involved calculating mean differences between uptake values and comparison using a random-effects model. A total of 16 articles, involving 423 participants, were included in the meta-analysis (10 carotid artery studies, five coronary artery studies, and one in peripheral vascular disease). Comparing 18F-NaF uptake in symptomatic versus asymptomatic atherosclerotic plaques, a mean difference of 0.43 (95% CI 0.29 to 0.57; p < 0.0001, I2 = 65%) was noted in studies comparing symptomatic and asymptomatic plaques in the same participant, with a significant difference in effect based on arterial territory studied (χ2 = 12.68, p = 0.0018). In studies of participants with and without symptomatic disease, there was no significant difference between symptomatic and asymptomatic plaques (mean difference 0.27, 95% CI -0.26 to 0.80, p = 0.28, I2 = 85%). PET imaging using 18F-NaF can detect differences in microcalcification between symptomatic and asymptomatic atherosclerotic plaques within, but not between, individuals, and thus, is a marker of symptomatic disease. The standardization of 18F-NaF PET imaging protocols, and its future use as a risk stratification tool or outcome measure, requires further study. (PROSPERO Registration ID: CRD42023451363).

Clinical Implication of Time of Ischaemic Stroke Among Post-Stroke Survivors from Eastern India: A Circadian Perspective.

The circadian variation in stroke occurrence is a well-documented phenomenon. However, the circadian effect on stroke outcome, particularly on post-stroke cognition, has not yet been fully elucidated. We aim to evaluate the influence of diurnal variation of stroke onset upon post-stroke cognition and development of post-stroke depression. Based on 4-hourly time period of stroke occurrence, 249 recruited cohorts were categorized into 6 groups. Several clinical and cognitive parameters were compared among the groups. Then, the mRNA expression of core clock genes in Peripheral Blood Mononuclear Cells were quantified and correlated with post-stroke outcomes among 24 acute phase cases with day-time or night-time stroke occurrence. Furthermore, the genetic susceptibility towards a higher number of cases in the morning was examined by genotyping CLOCK (rs1801260T/C, rs4580704G/C) and CRY2 (rs2292912C/G) genes variants in cases and 292 controls. In our study, the peak for highest incidence although observed during the early morning from 4 to 8 am, the nocturnal-onset stroke cases showed more severity (12.2 ± 5.67) at the time of admission irrespective of arterial territory involved. The night onset cases were also found to be more susceptible to develop language impairment and post-stroke depression in due course of time. Upon transcript analysis, circadian genes (BMAL1 and CRY1) were found to be downregulated in night-time cases than day-time ones during the acute phase of onset. In addition, those mRNA levels also showed a correlation with raw scores for language and depression. However, the difference in incidence frequency along a day did not reveal any genetic correlation. Therefore, we suggest night-time stroke to be positively associated with higher immediate severity and poor cognitive outcome than day-time injury and propose downregulation of circadian genes during the acute phase could be the underlying molecular mechanism for this.

Acute vestibular syndrome accompanying middle cerebral artery infarctions: a single-center study

Objectives: Acute vestibular syndrome (AVS) is a disease and disorder usually manifest with a single episode of sudden onset vestibular symptoms and signs, and may occur at any point along the vestibular pathway from the peripheral labyrinth to the vestibular cortex. This study presents the characteristics of the involved cortical area and clinical course in middle cerebral artery (MCA) territory infarction patients with central vestibular disorder. Methods: Files of patients diagnosed with acute ischemic stroke in the MCA territory were reviewed retrospectively between December 2020 and March 2022. All the patients were categorized into two groups (with or without AVS) and analyzed for comorbidities as well as smoking and drinking habits, and their data pertaining to the neurological examination, bedside neuro-otological examination, and laboratory and computerized tomography angiography findings were collected. Results: Seven hundred and sixty-eight patients with MCA territory infarction were included in the study. AVS incidence was calculated to be 13.3%. There was no statistically significant difference in the distribution of age and sex between patients with and without AVS. The involvement of the right side was significantly more prevalent in AVS patients. Distribution of patients with right-sided infarction: 11 with posterior superior temporal gyrus 17 with parieto-insular cortex, 16 with insular cortex and temporoparietal junction together, and 18 with more than one millimetric infarction in all three areas. Conclusions: Patients with acute vestibular syndrome, may have infarctions in the anterior circulation and most of them had no pathological neuro-otologic test findings.

Acute Ischemic Stroke After Russell’s Viper Snake Bite, Rare Presentation: A Case Report

Snake bitesare a global health hazard and are a noteworthy cause of mortality and morbidity especially in Southeast Asia. Cerebral complicationsafter snake bite are rare. It can be attributed to various factors such as vasculitis, vasospasm, endothelial damage; toxin-induced procoagulant effect, and disseminated intravascular coagulation. We present a case of a previously healthy 22-year-old woman who suffered acute multiple cerebral infarctions following Russell's viper bite. Imaging revealed significant non-hemorrhagic infarctions in the left middle cerebral artery territory and right pons, indicating rare yet severe neurological complications of viper envenomation. The patient experienced serious complications including rhabdomyolysis and acute kidney injury, ultimately leading to her demise due to aspiration pneumonia and septic shock. This case underscores the potential neurological impact of viper envenomation and underscores the challenges in managing delayed procoagulant effects of snake venom, despite the administration of anti-snake venom. Early detection and intervention remain vital in addressing such devastating outcomes.

Reliable infarction of the middle cerebral artery territory in C57BL/6 mice using pterygopalatine artery ligation and filament optimization - The PURE-MCAo model.

Current techniques for inducing intraluminal filamentous middle cerebral artery occlusion (fMCAo) in mice produce highly variable results and often cause additional infarcts in the posterior cerebral artery (PCA) territory. The aim of the current study was to develop a novel procedure to overcome these shortcomings. Male C57BL/6 mice were subjected to 60 min of fMCAo with cerebral blood flow monitored by laser Doppler flowmetry. The influence of the length of the occlusion filament coating and the combination of common carotid artery (CCA) or pterygopalatine artery (PPA) ligation on lesion volume and functional outcome 24 h after reperfusion was evaluated. The use of appropriate filament and PPA ligation while maintaining CCA perfusion prevented the development of infarcts in the PCA area, resulted in pure MCA infarcts (68.3 ± 14.5 mm3) and reduced the variability of infarct volumes by more than half (from 26-38% to 14% standard deviation/mean). Using an improved fMCAo procedure, we were able to produce PCA area-unaffected reproducible (PURE) infarcts exclusively in the MCA territory. Thus PURE-MCAo reduced outcome variability by more than 50%. Our results may thus help to reduce the number of animals in preclinical stroke research and to increase the reproducibility of the fMCAo model.

6538 Find me if you can! A Case of a "Well Placed Solitary Insulinoma" in "The Center" of an SACST

Abstract Disclosure: R. Kennedy: None. D.A. D'Alessio: None. A.V. Vella: None. Introduction: Selective arterial calcium stimulation testing (SACST) can be utilized in patients to localize solitary insulinomas when imaging is non diagnostic. While a heterogenous stimulation pattern suggests NIPHS, or multiple insulinomas this case uniquely demonstrates such a pattern with a solitary insulinoma. Clinical Case: The patient is a 48 year old female who presented to the emergency department (ED) for bizarre behavior which resolved with a sweetened drink. Serum glucose was 62 mg/dL, she was treated with IV dextrose and was discharged from the ED. She was referred to outpatient endocrinology for further evaluation where continuous glucose monitoring confirmed predominantly fasting hypoglycemia. Adrenal insufficiency was excluded. She was admitted for a 72 hour inpatient fast where the patient achieved hypoglycemia within 24 hours, with glucose 46 mg/dL (associated with neuroglycopenic symptoms), beta hydroxybutyrate &amp;lt; 0.18 mmol/L, insulin 3.9 mcIU/mL, proinsulin 157pmol/L, c-peptide 1.4 ng/mL and a glucose rise greater than 25mg/dL after glucagon administration. Sulfonylurea screen and insulin antibodies were negative; IGF1 within normal limits. These labs were consistent with hyperinsulinemic hypoglycemia. An MRI pancreas however did not reveal an insulinoma. The patient therefore underwent a SACST, demonstrating a 10 fold response in the territory of the gastroduodenal artery and splenic artery, as well as a 3 fold response in the superior mesenteric artery. This heterogenous pattern in addition to the marked response in each arterial territory raised the possibility of multiple insulinomas. However as there were no tumors present on imaging, medical management was initiated with close follow up. She was trialed with months of somatostatin analogs and diazoxide with minimal improvement in the frequency and severity of her hypoglycemia. About a year after her initial diagnosis, repeat abdominal imaging (CT and MRI) revealed an 8 mm arterial hyper-enhancing lesion in the body of the pancreas concerning for neuroendocrine tumor. Repeat SACST was performed, this time showing a greater than 10 fold response in all three arterial territories. Angiography showed a tumor blush that was visible when each of the three major arteries were injected sequentially. She underwent laparoscopic pancreatic enucleation. The lesion was located on the body of the pancreas, with histology confirming an insulinoma. The patient responded promptly post operatively; her symptoms resolved without further need of medical management. Conclusion: Our case shows that the interpretation of an SACST should take into account the arterial anatomy before ascribing a non-focal response to multiple territories of insulin hypersecretion. Presentation: 6/1/2024