Early focal electroencephalogram and neuroimaging findings predict epilepsy development after aneurysmal subarachnoid hemorrhage

INTRODUCTION

Seizures are a common complication of subarachnoid hemorrhage (SAH) in both acute and late stages: 10-20 % acute symptomatic seizures, 12-25 % epilepsy rate at five years. Our aim was to identify early electroencephalogram (EEG) and computed tomography (CT) findings that could predict long-term epilepsy after SAH.

MATERIAL AND METHODS

This is a multicenter, retrospective, longitudinal study of adult patients with aneurysmal SAH admitted to two tertiary care hospitals between January 2011 to December 2022. Routine 30-minute EEG recording was performed in all subjects during admission period. Exclusion criteria were the presence of prior structural brain lesions and/or known epilepsy. We documented the presence of SAH-related cortical involvement in brain CT and focal electrographic abnormalities (epileptiform and non-epileptiform). Post-SAH epilepsy was defined as the occurrence of remote unprovoked seizures ≥ 7 days from the bleeding.

RESULTS

We included 278 patients with a median follow-up of 2.4 years. The mean age was 57 (+/-12) years, 188 (68 %) were female and 49 (17.6 %) developed epilepsy with a median latency of 174 days (IQR 49-479). Cortical brain lesions were present in 189 (68 %) and focal EEG abnormalities were detected in 158 patients (39 epileptiform discharges, 119 non-epileptiform abnormalities). The median delay to the first EEG recording was 6 days (IQR 2-12). Multiple Cox regression analysis showed higher risk of long-term epilepsy in those patients with CT cortical involvement (HR 2.6 [1.3-5.2], p 0.009), EEG focal non-epileptiform abnormalities (HR 3.7 [1.6-8.2], p 0.002) and epileptiform discharges (HR 6.7 [2.8-15.8], p < 0.001). Concomitant use of anesthetics and/or antiseizure medication during EEG recording had no influence over its predictive capacity. ROC-curve analysis of the model showed good predictive capability at 5 years (AUC 0.80, 95 %CI 0.74-0.87).

CONCLUSIONS

Focal electrographic abnormalities (both epileptiform and non-epileptiform abnormalities) and cortical involvement in neuroimaging predict the development of long-term epilepsy. In-patient EEG and CT findings could allow an early risk stratification and facilitate a personalized follow-up and management of SAH patients.

Smoking-attributable mortality by sex in the 27 Brazilian federal units: 2019

OBJECTIVES

The aim of this study was to estimate smoking-attributable mortality (SAM) in the population aged 35 years and over in Brazil's 27 federal units by sex, in 2019.

STUDY DESIGN

This is an attributable mortality analysis.

METHODS

We applied a method dependent on the prevalence of smoking, based on the population attributable fractions. Data on mortality due to causes causally related to smoking were derived from Brazil's Death Registry, data on prevalence of smoking from a survey conducted in Brazil in 2019, and data on relative risks from five US cohorts. Crude and age-adjusted SAM rates were calculated by sex. Estimates of SAM were calculated by specific causes of death and major mortality groups for each federal unit by sex.

RESULTS

In 2019, smoking caused 480 deaths per day in Brazil. Although the SAM varied among the federal units, the pattern is not clear, with the greatest difference being between Rio Grande do Sul (crude rate: 248.8/100,000 inhabitants) and Amazonas (106.0/100,000). When the rates were adjusted by age, the greatest differences were observed between Acre (271.1/100,000) and Distrito Federal (131.1/100,000). SAM was higher in males; however, while the main specific cause of SAM in men was ischemic heart disease, in women it was chronic obstructive pulmonary disease. The major mortality group having the greatest impact on SAM across all federal units was the cardiometabolic diseases.

CONCLUSIONS

The variability in the burden of SAM in the different regions of Brazil reaffirms the need for SAM data disaggregated at the geographic level.

Mortality attributable to environmental tobacco smoke exposure in Spain in 2020

INTRODUCTION AND OBJECTIVES

Exposure to environmental tobacco smoke (ETS) is associated with increased mortality and morbidity. The objective of this study was to estimate the impact of ETS exposure in Spain on mortality in 2020 in the population aged 35 years and over.

METHODS

A method of estimating attributable mortality (AM) based on the prevalence of ETS exposure was applied. Prevalence data were obtained from a representative study conducted in Spain and the relative risks were derived from a meta-analysis. AM point estimates are presented along with 95% confidence intervals (95% CI), calculated using a bootstrap naive procedure. AM, both overall and by smoking habit, was estimated for each combination of sex, age group, and cause of death (lung cancer and ischemic heart disease). A sensitivity analysis was performed.

RESULTS

A total of 747 (95% CI 676-825) deaths were attributable to ETS exposure, of which 279 (95% CI 256-306) were caused by lung cancer, and 468 (95% CI 417-523) by ischemic heart disease. Three-quarters (75.1%) of AM occurred in men and 60.9% in non-smokers. When chronic obstructive pulmonary disease and cerebrovascular disease are included, the burden of AM is estimated at 2242 deaths.

CONCLUSIONS

ETS exposure is associated with 1.5% of all deaths from lung cancer and ischemic heart disease in the population aged 35 and over. These data underline the need for health authorities to focus on reducing exposure to ETS in all settings and environments.

Advanced echocardiography with left atrial strain and indexed left atrial 3D volume for predicting underlying atrial fibrillation after cryptogenic stroke

Introduction

Cryptogenic stroke (CS) represents one-third of ischemic strokes. Atrial fibrillation (AF) can be detected in up to 30% of CS. Therefore, there is a clinical need for predicting AF to guide the optimal secondary prevention strategy. The evidence about the role of advanced echocardiography, including left atrial 3D index volume and left atrial strain (LAS) techniques, to predict underlying AF in this setting is lacking.

Methods

From April 2019 to November 2021 seventy-eight consecutive patients with ischemic stroke or transient ischemic attack with ABCD2 scale ≥4 of unknown etiology were prospectively recruited. Echocardiography was performed during admission. All patients underwent 15 days wearable Holter monitoring. The primary outcome measure was AF detection during follow-up.

Results

Twenty -two patients (28%) developed AF. Patients in the AF group were older (81±6.3 vs 76.5±7.8 years; p=0.012). Left atrial (LA) diastolic indexed volume was higher in AF group (37.2±12.8 vs 29.7±11 ml/m2 p=0.01). 3D LA indexed volume were also higher in patients with AF (41.4±14 vs 32.2±10 ml/m2 p=0.009). LAS reservoir, LAS conduct and LAS contraction (LASct) were significantly lower in patients with AF (19±5.6 vs 32±10.3%; 9±4.5 vs 15±7.6; 10±5.3 vs 17±6.4, respectively, all p&lt;0.001). On multivariate analysis LASct &lt;13.5% and LA 3D indexed volume &gt;44.5 ml/m2 were independent predictors of AF (OR 10.9 [95% CI 1.09–108.2], p=0.042) (Table 1, Figure 1)

Conclusion

LASct &lt;13.5% and LA 3D indexed volume &gt;44.5 ml/m2 are independent predictors of underlying AF in patients with CS. Our results demonstrate the usefulness of advanced echocardiography in this challenging clinical setting.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Spanish Society of Cardiology

Glomerular filtration rate estimation for carboplatin dosing in patients with gynaecological cancers

Background

Carboplatin remains integral for treatment of gynaecological malignancies and dosing is based on glomerular filtration rate (GFR). Measurement via radiotracer decay [nuclear medicine GFR (nmGFR)] is ideal. However, this may be unavailable. Therefore GFR is often estimated using formulae that have not been validated in patients with cancer and/or specifically for gynaecological malignancies, leading to debate over optimal estimation. Suboptimal GFR estimation may affect efficacy or toxicity.

Methods

We surveyed several UK National Health Service Trusts to assess carboplatin dosing practise. We then explored single-centre accuracy, bias and precision of various formulae for GFR estimation, relative to nmGFR, before validating our findings in an external cohort.

Results

Across 18 Trusts, there was considerable heterogeneity in GFR estimation, including the formulae used [Cockcroft–Gault (CG) versus Wright], weight adjustment and area under the curve (AUC; 5 versus 6). We analysed 274 and 192 patients in two centres. Overall, CamGFR v2 (a novel formula for GFR estimation developed at Cambridge University Hospitals NHS Foundation Trust) excelled, showing the highest accuracy and precision. This translated into accuracy of hypothetical carboplatin dosing; nmGFR-derived carboplatin dose fell within 20% of the Cam GFR v2-derived dose in 86.5% and 87% of patients across the cohorts. Among the CG formula and its derivatives, using adjusted body weight in those with body mass index ≥25 kg/m² [CG-adjusted body weight (CG-AdBW)] was optimal. The Wright and unadjusted CG estimators performed most poorly.

Conclusions

When compared with nmGFR assessment, accuracy, bias and precision varied widely between GFR estimators, with the newly developed Cam GFR v2 and CG-AdBW performing best. In general, weight (or body surface area)-adjusted formulae excelled, while the unadjusted CG and Wright formulae or the use of AUC6 (versus nmGFR AUC5) produced risk of significant overdose. Thus, individual centres should validate their GFR estimation methods. In the absence of validation, CG-AdBW or CamGFR v2 is likely to perform well while unadjusted CG/Wright formulae or AUC6 dosing should be avoided.

•

Despite therapeutic advances, carboplatin is still used repeatedly for treatment of gynaecological cancers.

•

Between centres, there is heterogenous use of GFR estimation methods for carboplatin dosing.

•

The novel CamGFR v2 and CG-AdBW are the most accurate estimators.

•

The Wright formula, unadjusted CG and the use of AUC6 with estimated GFR should all be avoided.

•

If internal validation unavailable, centres should use CamGFR v2 or CG-AdBW for GFR estimation.

Intracoronary thrombus assessment with cardiac computed tomography angiography in a deferred stenting strategy

Funding Acknowledgements

Type of funding sources: None.

Background.

Cardiac computed tomography angiography (CCTA) is precise in non-invasive coronary atherosclerosis characterization but its value in the diagnosis of intracoronary thrombus remains unknown. Therefore, our aim was to evaluate the diagnostic accuracy of CCTA for intracoronary thrombus and stenosis detection in acute coronary syndromes (ACS) with high thrombus burden selected for a deferred stenting (DS) strategy.

Methods.

We systematically performed a CCTA in consecutive DS patients 24 hours before the scheduled repeated coronary angiography that also included optical coherence tomography (OCT) imaging. Intracoronary thrombus and residual stenosis were blindly and independently evaluated by both non-invasive and invasive diagnostic tests. Agreement was determined per lesion using weighted Kappa (K) coefficient and  absolute intra-class correlation coefficient (ICC). A stratified analysis according to OCT-detected thrombus burden was also performed.

Results.

Thirty lesions in 28 consecutive patients with a large thrombus burden were analyzed. Concordance between CCTA and repeated coronary angiography in thrombus detection was good (K= 0.554; p&lt; 0.001), but both showed a poor agreement with OCT. CCTA needed &gt;11.5% thrombus burden on OCT to obtain adequate diagnostic accuracy. The lesions detected by angiography were more frequently classified as red thrombus (76.5 vs 33.3%; p= 0.087) on OCT. CCTA showed an excellent concordance with coronary angiography in diameter stenosis (ICC= 0.85; p&lt; 0.001), and was able to identify all the patients with severe residual stenosis.

Conclusion.

CCTA is able to assess intracoronary thrombus. Although CCTA showed just a good concordance with angiography in thrombus detection, the agreement in residual stenosis was excellent. Thus, in patients with a high-thrombus burden CCTA may substitute repeat angiography in patients considered for DS. Abstract Figure.

Exploring the feasibility of the aorta to pulmonary artery ratio as novel risk marker of acute aortic syndromes in dilated aorta without conventional criteria for surgery

Funding Acknowledgements

Type of funding sources: None.

Introduction

Based on current guidelines, surgery indication of thoracic ascending aortic aneurysm (TAAA) is mainly driven by the aortic diameter. However, most cases of TAAA acute complications occur in patients who did not previously meet the 55 mm criteria for preventive surgical replacement (1). Both aorta indexed to height and to body surface area have been proposed as possible solution but indexed diameters of healthy aortas widely  vary (2). Accordingly, new individualized biomarkers to improve the risk stratification of dilated aorta without a conventional criteria for surgery remain an unmet clinical need. Since aorta and pulmonary artery have an established ratio in general population (upper normal ratio of 1.2) (3), the aorta-to-pulmonary-artery ratio (A:PA) may better define the wall stress in a dilated aorta, overcoming the individual limitations of conventional size criteria.

Purpose

The aim of our study is to find a novel aortic indexed diameter with better prognostic performance. Therefore, we aimed to explore the feasibility of using the A:PA as risk predictor in TAAA with  aortic diameter &lt; 55 mm.

Methods

All consecutive patients with an acute aortic syndrome (AAS), diagnosed by CT scan in our tertiary hospital between January 2010 and June 2021 undergoing surgical repair, were retrospectively analyzed. Patients with pulmonary hypertension were excluded to prevent distortions in the pulmonary artery diameter. Basic clinical characteristics regarding indications of surgery were collected along with measurements of the aortic maximum diameter and pulmonary artery maximum diameter, obtained by multiplane reconstruction (Figure, Panels A, B). Patients were categorized into three groups based on aortic diameter terciles: group A included patients with &lt; 47 mm, group B ≥ 47 mm but &lt; 55 mm and group C ≥ 55 mm. Considering a high risk of concomitant confounding factors the lower tercile was subsequently excluded of the analysis.

Results

A total 48 patients were included. 69% of the patients had an aortic diameter that would have not fulfilled a preventive surgery indication.  Two patients had bicuspid aortic valve, both of them with aortic aneurysms &gt; 55 mm. None had high risk connective tissue disorders. There were no significant differences in baseline characteristics between the groups (Table 1). 

A

PA ratio was similar in group B and C [1.91 (0.41) versus 2.11(0.45); p = 0.251], suggesting a similar aortic wall stress between aortas despite the difference in aortic diameters [49.5 mm (5.0) versus 58 mm (4.7); p &lt; 0.001] (Figure 1, Panels C, D).

Conclusions: Our findings suggest that the A

PA ratio may be a promising risk stratification biomarker for TAAA without a conventional criteria for preventive surgery. This novel parameter should be prospectively tested in cohorts of TAAA. To the best of our knowledge, this is the first attempt to describe the usefulness of this parameter. Abstract FIGURE 1  Abstract TABLE 1

CHA2DS2VASC score for predicting atrial fibrillation in patients with cryptogenic stroke

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Spanish Society of Cardiology

Introduction

CHA2DS2-VASc Score is widely used to predict thromboembolic risk in patients with Atrial Fibrillation (AF). However the role of CHA2DS2-VASC score for predicting AF in patients with cryptogenic stroke (CS) remains unknown.

Methods

Sixty-three consecutive patients with ischemic stroke or transient ischemic attack with ABCD2 scale≥4 of unknown etiology, were prospectively recruited. They were classified according to

CHA2DS2-VASc Score: group 1 (score ≤ 5), and group 2 (score &gt;5). The primary outcome measure was the occurrence of AF during clinical follow-up.

Results

Twenty-six (41%) patients had a CHA2DS2VASC score &gt; 5 (group 2). Patients in this group were older (81 ± 5.5 vs 75 ± 8 years; p &lt; 0.001) and more frequently female (73% vs 43% p = 0.019). Patients in group 2 present more often hypertension (84% vs 43% p = 0.001), diabetes (38% vs 11%, p = 0.009) , dyslipidemia 77% vs 49%, p = 0.024), and a prior history of coronary artery disease (27% vs 5%, p = 0.026). Notably, patients with higher CHA2DS2VASC showed worse left atrial ejection fraction (41.7 ± 13.1 vs 52.2 ± 15%, p = 0.009) and worse left atrial strain reservoir (21.5 ± 7.1 vs 33.8 ± 11%, p &lt; 0.001), conduct (9.5 ± 4.8 vs 16.6 ± 8.4%;p &lt; 0.001) and contraction (12 ± 4.6 vs 17.2 ± 7.3, p = 0.002). During follow-up AF was detected more often in group 2 (42% vs 11% p = 0.006). In multivariate analysis CHA2SD2VAS &gt; 5 was an independent predictor of AF in patients with CS (HR 7.3 [95% CI 1.2-45.6] p = 0.032)

Conclusion

A CHA2DS2VASC score &gt;5 is an independent predictor of AF in patients with CS. This score provides a new clinical tool to inform clinicians with regards to the optimal treatment of these challenging patients

Feasibility of blood speckle imaging parameters as predictors of intracavitary thrombus in apical aneurysm

Funding Acknowledgements

Type of funding sources: None.

Introduction

In patients with apical aneurysm, left ventricular thrombus (LVT) is a major complication associated with systemic embolism. Likely, abnormalities in apical wall contraction produce stagnant flow which leads to the thrombus formation. Currently, there is a lack of knowledge about predictors of thrombus in such patients. However, new imaging techniques might be able to identify flow properties useful for risk stratification. Specifically, blood speckle imaging (BSI), a technology based on high-frame rate ultrasound, is a promising pattern-matching technique that could allow a comprehensive assessment of blood flow in patients with apical aneurysms (1,2).

Purpose

The aim of the study was to demonstrate the feasibility of obtaining quantitative and qualitative measurements with BSI in patients with apical aneurysms and to explore which parameters may be associated with LVT.

Methods

We examined cases of patients with apical aneurysm and LVT studied in our tertiary center. In order to exclude from our analysis the pro-inflammatory effects of the acute event, patients with thrombus formation within the first month after the ischemic event were excluded. Patients with current presence of thrombus were also discarded. A control group of patients with apical aneurysm but without history of LVT was included.

A basic 2-dimensional echocardiography study was obtained, along with BSI images. BSI acquisitions were performed with a 29 cm/s (2.5 mHz) scale. Data regarding vortex flow were collected, including its presence, area, length, besides area without BSI vectors (Image 1). All measures were indexed by telediastolic left ventricular volume.

Results

Eight patients with apical aneurysms were enrolled in the study, four of them with history of LVT. Although in patients with history of thrombus a larger vortex area was found  (Table 1), none of the differences in the BSI parameters was statistically significant.

Conclusion

This study shows for the first time the feasibility of BSI for characterizing complex flow patterns such as vortex in patients with apical aneurysms. Explorations in larger cohorts of patients are needed to prove significant findings with this technology in the future. Abstract Figure. Image 1  Abstract TABLE 1

1640 Pulmonary valve in carcinoid disease: be suspicious of functional assessment

Carcinoid heart disease occurs in 50% of patients with carcinoid syndrome, especially on serotonin-secreting neuroendocrine tumors (NET) [1, 2]. Carcinoid heart disease"s typical findings are carcinoid plaques, composed of smooth muscle, myofibroblasts and endothelium. These plaques, most frequently localized on the right side valvular cusps and leaflets, produce fixation and retraction, causing regurgitation and/or stenosis [3, 4, 5]. Left-sided heart disease is rare (&lt;10%), as serotonin is purified in the pulmonary circulation [3, 6, 7].

We present the case of a 67 year old female patient with previous history of right ovarian NET. She presented with dyspnea (II-III NYHA functional class), and slight edema in lower limbs. She denied symptoms of carcinoid syndrome before or after the ovarian surgery.

Examination showed an increased jugular venous pulse.

Transthoracic echocardiography (TTE) showed severely dilated right cavities and a rigid, immobile tricuspid valve, with massive tricuspid regurgitation (Panel A, 1). Anatomy of

pulmonary valve was not properly visualized but jet area of pulmonary regurgitation was small (Panel A, 2). Left cavities and valves were intact.

As TTE was not anatomically conclusive, a cardiac magnetic resonance (CMR) and a cardiac computed tomography (CCT) were performed to assess the carcinoid involvement of pulmonary valve.

CMR showed severely dilated right ventricle with mild impairment of systolic function (Panel A, 3). Based on phase contrast imaging, pulmonary regurgitation fraction was 14%,

suggestive of a mild grade. However, CCT showed a diffuse thickening of the pulmonary valve, with complete opening during diastole (Panel A, 4, arrowhead). Finally, the patient underwent replacement of tricuspid valve and pulmonary valve for biological prosthesis without complications.

Our case is remarkable because it highlights the limitations of the functional assessment of pulmonary regurgitation in the presence of a concomitant massive tricuspid valve regurgitation, since the rapid equalization of pressure between pulmonary artery and right ventricle reduces the expression of pulmonary regurgitation. For these reason, the anatomic assessment of the pulmonary valve is mandatory to stage the involvement of pulmonary valve in carcinoid disease.

Abstract 1640 Figure. Panel A

P845 Deep vein thrombosis, pulmonary embolism and patent foramen ovale: a lethal mix

A 50-year-old woman without remarkable medical history was admitted at the Emergency Department for acute dyspnoea. The patient had been recently submitted to C5-C6 microdiscectomy. She was tachypneic and oxygen saturation was 88%. CT angiography showed bilateral pulmonary embolism (PE) (Figure 1A, yellow arrowheads) with signs of right ventricle overload. Bilateral deep vein thrombosis was also confirmed. The patient was admitted at the Intensive Care Unit, clinically stable. Few hours later, she presented sudden hemodynamic and respiratory deterioration, requiring invasive mechanical ventilation and vasopressors. Due to recent cervical surgery, systemic fibrinolysis was ruled out. Decision for percutaneous thrombectomy and inferior vena cava filter placement was made. Nevertheless, percutaneous thrombectomy was unsuccessful due to the impossibility to catheterize pulmonary artery. Contrast injection demonstrated that the guiding catheter was located in the left atrium (Figure 1B), suggesting a patent foramen ovale (PFO). Transoesophageal echocardiogram confirmed the presence of a 5x6 mm PFO with right-to-left shunt (Figures 1C – yellow arrows, and 1D). In addition, a 4 cm mobile mass attached to the aortic valve and protruding throughout the left ventricle outflow tract was visualized, suggesting paradoxical embolism (Figure 1E – white arrows). Accordingly, open surgical approach with pulmonary thrombectomy, PFO closure and removal of the left-sided thrombus was decided. Unfortunately, despite careful cannulation, thrombus was not found when aortic valve was inspected. Worst suspicions were confirmed, when the patient presented non-reactive mydriatic pupils. A brain CT showed signs of an extensive bihemisferic ischemic stroke (Figure 1F) presumably related to cerebral embolization of aortic thrombus. The patient finally died. Autopsy study was not consented.

PFO has been associated with paradoxical embolisms and risk of stroke in PE. This case strikingly illustrates that treatment of these patients may be challenging in spite of an adequate diagnosis and management.

Abstract P845 Figure.

1095 Effective image-guided medical management in effusive constrictive pericarditis

A 59 year old man was admited to hospitalization for persistent chest pain related to acute pericarditis. Within the admision tests, a transthoracic echography was performed, showing a moderate pericardial effusion with ventricular septal bounce and significant respiratory variations in mitral and tricuspid inflows, all of it consistent with effusive-constrictive pericarditis (Panel A). Anti-inflammatory treatment with ibuprofen and colchicine was started.

During the first 48 hours of admission there was a clinical and hemodinamic worsening in the patient’s condition that forced the performance of a pericardial window, obtaining a very little quantity of dense pericardial fluid. Looking for a more accurate study of the pericardium, a cardiovascular magnetic resonance (CMR) was performed, revealing a thick heterogeneous pericardial effusion (Panel B) and a significant late gadolinium enhancement of both pericardial layers (Panel C). All these findings where consistent with an effusive constrictive pericarditis with persistent inflammatory activity despite high doses of conventional inflammatory treatment. Furthermore, the growth of Propionibacterium acnes in the pericardial fluid disclosed the etiology of this condition.

Medical treatment was enhanced with high doses of intravenous corticosteroid, ceftriaxone and doxycycline. During the following days, the patient showed an excellent response achieving the complete clinical and echocardiographic relief of constrictive signs (Panel D).

Effusive constrictive pericarditis is characterized by the presence of pericardial effusion and constriction secondary to an inflammatory process of the pericardium. Pericardiectomy might be necessary in case of failure of medical treatment, a very common scenario in this kind of .pericarditis.

Our case is remarkable because it demonstrates the value of CMR to detect persistent inflammation of pericardium despite high doses of conventional medical treatment for pericaricarditis guiding the successful escalation to intravenous corticosteroid and avoiding the risk of an unnecessary cardiac surgery.

Abstract 1095 Figure.

Correction: Safety and utility of image-guided research biopsies in relapsed high-grade serous ovarian carcinoma-experience of the BriTROC consortium

This article was originally published under a CC BY NC SA License, but has now been made available under a CC BY 4.0 License.