Extensive intracranial arterial dolichoectasia involving distal branches of intracranial arteries: two cases report and review of the literature

With the rapid development of noninvasive angiography techniques such as Magnetic Resonance Angiography (MRA) and Computer Tomography Angiography (CTA), more and more patients with intracranial arterial dolichoectasia (IADE) have been found, and clinical studies on this kind of vascular abnormity have become hot subjects in neurology. We presented two young patients with IADE extensively involving the branches of intracranial arteries, which were different from patients described in other articles. A young male patient was diagnosed with IADE after examination on admission, and further detailed examination revealed that the patient had osteropathia striata. Another young woman had an arterial malformation that mainly affected the distal branch of the intracranial artery. These two cases give us another perspective to look into IADE.

Experimental models of cardiac physiology and pathology

Experimental models of cardiac disease play a key role in understanding the pathophysiology of the disease and developing new therapies. The features of the experimental models should reflect the clinical phenotype, which can have a wide spectrum of underlying mechanisms. We review characteristics of commonly used experimental models of cardiac physiology and pathophysiology in all translational steps including in vitro, small animal, and large animal models. Understanding their characteristics and relevance to clinical disease is the key for successful translation to effective therapies.

Vascular biomarkers and digital ulcerations in systemic sclerosis: results from a randomized controlled trial of oral treprostinil (DISTOL-1)

INTRODUCTION

Although there is abundant evidence of vascular perturbation from studies of peripheral blood in systemic sclerosis (SSc), there are few data about the ability to use biomarkers of vascular injury and growth factors to predict vascular outcomes and response to therapy. We sought to explore the association between candidate vascular biomarkers and digital ulcerations (DU) in a clinical trial context.

METHODS

We examined 19 circulating vascular, angiogenic, and inflammatory biomarkers in 124 patients with scleroderma and DU who participated in a randomized controlled trial of oral treprostinil diolamine (ClinicalTrials.gov identifier NCT00775463). Correlation, regression, and random forest analyses were conducted to assess biomarker relationships in response to drug treatment.

RESULTS

Over the 20-week trial, 82 (66%) patients had their cardinal ulcer completely heal, 54 (44%) developed new ulcers, and 72 (58%) had complete healing of all ulcers; mean change in ulcer burden comparing week 20 with baseline was - 0.36 ± 1.70. Nineteen biomarkers were analyzed for their association and ability to predict clinical DU outcomes. After adjusting for multiple comparisons, no individual biomarker (baseline level, week 20 level, or change over time) was significantly associated with any of the clinical outcomes, suggesting that traditional vascular, angiogenic or inflammatory drivers are not predictive of ulcer fate.

CONCLUSIONS

The lack of strong response to any of the vascular, angiogenic, or inflammatory markers suggest that these pathways are not primary drivers in the development of DU clinical outcomes in a SSc population with prevalent DU.

KEY POINTS

• Currently we lack robust biomarkers to predict vascular outcomes or response to therapy in scleroderma patients with Raynaud's phenomenon.• Longitudinal assessment of vascular biomarkers in a clinical trial setting provides a unique opportunity to define biomarkers that predict vascular outcomes.• In a randomized controlled trial of oral treprostinil diolamine for treatment of scleroderma-associated digital ulcers, biomarkers involved in several vascular, inflammatory, and angiogenic pathways did not predict short-term clinical response to therapy or digital ulcer outcomes.• Further study of these and other biomarkers should be considered in Raynaud's clinical trials in scleroderma patients without prevalent digital ulcers.

Cerebrovascular disease: how serum phosphorus, vitamin D, and uric acid levels contribute to the ischemic stroke

Background

Associations between serum phosphorus level and the incidence of ischemic stroke are not clear. This study aimed to measure serum phosphorus, vitamin D3, and uric acid levels in ischemic stroke patients compared to a population without ischemic stroke.

Methods

In this cross-sectional study, 133 patients admitted to a neurology ward with the diagnosis of ischemic stroke were compared with a control group comprising 133 age- and gender-matching individuals. The presence of ischemic stroke was confirmed by a neurologist based on clinical signs, symptoms, brain CT scan, and MRI. Blood samples were taken from all patients in the first 24 h of admission to measure serum phosphorus, vitamin D3, calcium, and uric acid levels.

Results

According to the results of this study, uric acid medians in patients with stroke and controls were 4.9 [3.8–6.4] and 3.9 [3.5–4.9] mg/dL, respectively (p < 0.001). Median phosphorus and vitamin D levels were significantly lower in stroke patients than the controls (3.6 [3.02–4.21] vs. 4.2 [3.8–4.6]) and (15.1 [8.2–27.9] vs. 22.7 [10.4–39.2]), respectively. Multiple logistic regression analysis showed that the ischemic stroke was positively associated with the vitamin D level and negatively correlated with the uric acid level. The phosphorus level was not significantly predictive of ischemic stroke.

Conclusion

Lower serum levels of vitamin D3 and higher levels of uric acid were associated with ischemic stroke. There are still unknowns about the role of these indicators on ischemic stroke and it requires further studies.

Prediction contribution of the cranial collateral circulation to the clinical and radiological outcome of ischemic stroke

BACKGROUND AND AIM

The extent of penumbra tissue and outcome in stroke patients depend on the collateral cranial vasculature. To provide optimal individualized care for stroke patients in the emergency room setting we investigated the predictive capability of a stringent evaluation of the collateral vessels in ischemic stroke on clinical outcome and infarct size.

METHODS

We retrospectively studied uniform clinical and radiological data of 686 consecutive patients admitted to the emergency department with suspected acute ischemic stroke. Cranial collateral vasculature status was graded using the initial CT-angiography. Outcome was measured by mRS, NIHSS and final infarct size at hospital discharge. All data were used to build a linear regression model to predict the patients´ outcome.

RESULTS

Univariate and multivariate analyses showed significant effects of the whole brain collateral vessel score on all outcome variables. Atherosclerosis and piale collateral status were associated with the final infarct volume (FIV). Atherosclerosis and age were associated with the NIHSS at discharge. The presence of atherosclerosis, glucose level on admission and age were associated with the mRS at discharge. The multivariate models were able to predict 29% of the variance of the mRS at discharge, 24% of the variance in FIV and 17% of the variance of the NIHSS at discharge. The whole brain collateral status and the presence of atherosclerosis were the most relevant predictors for the clinical and radiological outcome.

CONCLUSION

The whole brain collateral vasculature status is clearly associated with clinical and radiological outcome but in a multivariate model seems not sufficiently predictive for FIV, mRS and NIHSS outcome at discharge in non-preselected patients admitted to the emergency department with ischemic stroke.

Association of residential air pollution, noise, and greenspace with initial ischemic stroke severity

BACKGROUND AND PURPOSE

A number of environmental risk factors of acute ischemic stroke have been identified, but few studies have evaluated the influence of the outdoor environment on stroke severity. We assessed the association of residential ambient fine particulate matter air pollution (PM_2.5), noise, and surrounding greenspace with initial stroke severity.

METHODS

We obtained data on patients hospitalized with acute ischemic stroke from a hospital-based prospective stroke register (2005-2014) in Barcelona. We estimated residential PM_2.5 based on an established land use regression model, greenspace as the average satellite-based Normalized Difference Vegetation Index (NDVI) within a 300 m buffer of the residence, and daily (Lday), evening (Levening), night (Lnight) and average noise (Lden) level at the street nearest to the residential address using municipal noise models. Stroke severity was assessed at the time of hospital presentation using the National Institute of Health Stroke Scale (NIHSS).We used logistic regression and binomial models to evaluate the associations of PM_2.5, greenspace, and noise with initial stroke severity adjusting for potential confounders.

RESULTS

Among 2761 patients, higher residential surrounding greenspace was associated with lower risk of severe stroke (OR for NIHSS>5, 0.75; 95% CI: 0.60-0.95), while, living in areas with higher Lden was associated with a higher risk of severe stroke (OR, 1.30; 95% CI: 1.02-1.65). PM_2.5 was not associated with initial stroke severity.

CONCLUSIONS

In an urban setting, surrounding greenspace and traffic noise at home are associated with initial stroke severity, suggesting an important influence of the built environment on the global burden of ischemic stroke.

Work-unit organizational changes and risk of cardiovascular disease: a prospective study of public healthcare employees in Denmark

PURPOSE

The impact of organizational change at work on cardiovascular disease (CVD) among employees is poorly understood. We examined the longitudinal associations between different types of work-unit organizational changes and risk of CVD among employees.

METHODS

We used multilevel mixed-effects parametric survival models to assess the risk of incident ischemic heart disease and stroke (72 events) during 2014 according to organizational changes in 2013 among 14,788 employees working in the same work unit from January through December 2013. We excluded employees with pre-existing CVD events between 2009 and 2013. Data on organizational changes defined as mergers, split-ups, relocations, change in management, employee layoffs, and budget cuts were obtained from work-unit managers (59% response).

RESULTS

There was an excess risk of CVD in the year following change in management (HR 2.04, 95% CI 1.10-3.78) and employee layoff (HR 2.44, 95% CI 1.29-4.59) in the work unit relative to no change. Exposure to any organizational change also suggested increased risk of CVD (HR 1.48, 95% CI 0.91-2.43). Including perceived stress as mediator in the regression models attenuated the point risk estimates only slightly, indicating no important mediation through this psychosocial factor.

CONCLUSIONS

Work-unit organizational change may be associated with excess risk of incident CVD among the employees relative to stable workplaces.

Hyponatremia in Acute Stroke Patients: Pathophysiology, Clinical Significance, and Management Options

BACKGROUND

Hyponatremia is frequent in acute stroke patients, and it is associated with worse outcomes and increased mortality.

SUMMARY

Nonstroke-related causes of hyponatremia include patients' comorbidities and concomitant medications, such as diabetes mellitus, chronic kidney disease, heart failure, and thiazides. During hospitalization, "inappropriate" administration of hypotonic solutions, poor solute intake, infections, and other drugs, such as mannitol, could also lower sodium levels in patients with acute stroke. On the other hand, secondary adrenal insufficiency due to pituitary ischemia or hemorrhage, syndrome of inappropriate antidiuretic hormone secretion, and cerebral salt wasting are additional stroke-related causes of hyponatremia. Although it is yet unclear whether the appropriate restoration of sodium level improves outcomes in patients with acute stroke, the restoration of the volume depletion remains the cornerstone of treatment in hypovolemic hyponatremia. In case of hyper- and euvolemic hyponatremia, apart from the correction of the underlying cause (e.g., withdrawal of an offending drug), fluid restriction, administration of hypertonic solution, loop diuretics, and vasopressin-receptor antagonists (vaptans) are among the therapeutic options. Key Messages: Hyponatremia is frequent in patients with acute stroke. The plethora of underlying etiologies warrants a careful differential diagnosis which should take into consideration comorbidities, concurrent medication, findings from the clinical examination, and laboratory measurements, which in turn will guide management decisions. However, it is yet unclear whether the appropriate restoration of sodium level improves outcomes in patients with acute stroke.

Causes of Acute Stroke: A Patterned Approach

Acute stroke is a leading cause of morbidity and mortality in the United States. Acute ischemic strokes have been classified according to The Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification system, and this system aids in proper management. Nearly every patient who presents to a hospital with acute stroke symptoms has some form of emergent imaging. As such, imaging plays an important role in early diagnosis and management. This article reviews the imaging patterns of acute strokes, and how the infarct pattern and imaging characteristics can suggest an underlying cause.

Temporal trend analysis of stroke and salt intake: a 15-year population-based study

Objectives: The aim of this study was to evaluate temporal trends of salt intake with stroke incidence, stroke subtypes, and blood pressure in an adult population.Methods: Data were extracted from Isfahan Salt Study. The stroke incidence rate, average salt intake, systolic and diastolic blood pressure in adults, aged over 18 years were considered from 2000 to 2014. The Average Annual Percent Changes (AAPC), parallelism, and the coincidence of trends were estimated, using a permutation test.Results: The trend of salt intake was increased from 2010 to 2014 (AAPC = +1.59, P-value = 0.004). The trend of the stroke incidence rate was nonlinear with two change points in 2003 and 2009. The overall stroke incidence rate increased by 6.65% per year (95% CI: 1.66, 11.8, P-value = 0.015). The temporal trend changes of stroke incidence rate were steeper in patients who aged 40-45 and over 50 years (+6 to +11.5%) than in patients who aged 19-40 and 45-50 (range: -3.3% to 0). The parallelism hypothesis of longitudinal changes between salt intake and ischemic stroke was accepted in patients, aged <50 years (P-value = 0.871).Conclusions: The average salt intake and its cone-shaped variance over 15 years of the study, indicated that salt intake reduction programs and policies were effective to stop associating intake increase until 2007, however, associated intake was increased since that time, which necessitates performing preventive programs. More importantly, the trend of salt intake and ischemic stroke was similar in patients who aged <50 years, regardless of considering their blood pressure.

Serum Neurofilament Light Chain Concentration Correlates with Infarct Volume but Not Prognosis in Acute Ischemic Stroke

BACKGROUND AND PURPOSE

We studied serum neurofilaments diagnostic value in patients with acute ischemic stroke (AIS) or TIA and evaluated any correlation with symptom severity, cerebral infarction volume, aetiology, and clinical outcome.

METHODS

One hundred and thirty-six patients (101 with AIS, and 35 with TIA) were included. Acute-phase serum neurofilament light chain (sNfL) was analyzed with a novel ultrasensitive single molecule array (Simoa). Cerebral infarction volume was measured from brain computed tomography in the subacute phase (>2 days). Stroke aetiology was defined by trial of ORG 10172 in acute stroke treatment classification, severity by National Institute of Health stroke scale (NIHSS) and the degree of disability by the Modified Rankin Scale (mRS) after 90 days.

RESULTS

sNfL was markedly higher in patients with AIS (89.5 pg/mL [IQR: 44.7-195.3]) than with TIA (25.2 pg/mL [IQR: 14.6-48.0]), P= <.001), also after adjusting for age, NIHSS, and stroke volume (P= .003). In receiver operating characteristic analysis, sNfL concentration greater than or equal to 49 pg/mL proved to be the best cut-off value to differentiate between patients with stroke and those with TIA (sensitivity of 73% and specificity of 80%). sNfL concentration significantly correlated with cerebral infarction volume (r = .413, P= <.001), this association remained significant after adjusting for established predictors (P= .019). Patients with AIS due to cardioembolism or large artery atherosclerosis had the highest sNfL concentrations. NIHSS on admission (r = .343, P = <.001) and mRS scores after 3 months (r = .306, P = .004) correlated with sNfL concentration, however functional outcome 3 months after stroke was not associated with sNfL after adjusting for potential confounders.

CONCLUSIONS

Cases with stroke were distinguishable from those with TIA following the determination of sNfL in the blood samples. The presence and amount of axonal damage estimated by sNfL correlated with the final cerebral infarction volume but was not predictive of degree of disability.

Association between post-procedural hyperoxia and poor functional outcome after mechanical thrombectomy for ischemic stroke: an observational study

BACKGROUND

The actual effects of oxygen therapy on patients who have suffered a stroke are still unknown, and its recommendation as a routine measure in emergency services remains controversial. The aim of this study is to determine the effect of hyperoxia in functional recovery in patients with ischemic stroke who underwent intra-arterial mechanical thrombectomy (IAMT).

METHODS

A prospective observational cohort study that included all adult patients consecutively admitted to the intensive care unit (ICU) due to an ischemic stroke in the anterior cerebral circulation and following an IAMT intervention, between 2010 and 2015. All patients were intubated and connected to mechanical ventilation for the intra-arterial therapy, receiving supplementary oxygen to achieve saturations above 94%. Two groups were established regarding oxygen partial pressure (paO₂) reached. It was based on a single ICU admission blood gas analysis. The hyperoxia group was defined as paO₂ > 120 mmHg. We measured functional recovery in each of the groups according to the modified Rankin scale after 90 days.

RESULTS

For the analysis, a total of 333 patients were included. High levels of paO₂ were mostly related to higher scores in modified Rankin scale (mRS) after 90 days. There were 60.6% cases with mRS ≥ 4 and 70.6% with mRS ≥ 3 in the hyperoxia group, compared to 43.0% and 56.1% in the paO₂ ≤ 120 group, p < 0.01, respectively. Mortality was higher in the hyperoxia group, 28.6% vs 18.7%, p = 0.04. After regression adjustment by confounding factors, poor functional outcome was still significantly higher in the hyperoxia group, for both mRS ≥ 4 and mRS ≥ 3: OR 2.2.7, IC 95%, 1.22-4.23, p = 0.01 and OR 2.07, IC 95%, 1.05-4.029, p = 0.04, respectively. Both the National Institute of Health Stroke Scale Score (NIHSS) values at 24 h after the IAMT and the days of ICU stay were significantly higher in the hyperoxia group.

CONCLUSIONS

In patients with ischemic stroke in the anterior cerebral circulation treated with IAMT, we found an association between admission PaO2 > 120 mmHg and worse functional outcome 90 days after ischemic stroke, but this association needs further confirmation by other studies.

Intravenous tissue plasminogen activator for ischemic stroke in early pregnancy dosed by actual body weight

Introduction:

Few published reports highlight intravenous tissue plasminogen activator use during the first trimester of pregnancy and provide outcomes for mother and fetus. Little guidance is available regarding body weight dosing of intravenous tissue plasminogen activator during pregnancy.

Methods:

Here, we present a patient who received intravenous tissue plasminogen activator in the emergency department during her first trimester of pregnancy for the treatment of an acute ischemic stroke. Outcomes are presented for mother and fetus, as well as discussion about the dosing weight utilized for the intravenous tissue plasminogen activator dose calculation.

Results:

A 35-year-old, Gravida 7 Para 6, presented to the emergency department at 9 weeks gestation with acute stroke symptoms. Her initial National Institutes of Health Stroke Scale was 7. Imaging revealed a hyperdense right middle cerebral artery sign. Intravenous tissue plasminogen activator was administered 57 min after her arrival and based on her actual body weight during pregnancy. Post tissue plasminogen activator imaging revealed recanalization of the vessel and the patient’s National Institutes of Health Stroke Scale was 0. The patient progressed to delivery of a healthy female infant. The patient did not experience any bleeding complications throughout pregnancy.

Conclusion:

We present positive outcomes of a mother and fetus after receipt of intravenous tissue plasminogen activator using actual body weight during the first trimester of pregnancy for an acute ischemic stroke. Additional information is necessary to provide recommendations for the application to future patients in early pregnancy.

Mechanical thrombectomy and the future of acute stroke treatment

After being staggered by numerous negative trials in 2013, the interventional stroke community saw four years of vindication for mechanical thrombectomy showing efficacy and safety, even beyond a hopeful 6-8 hour window out to 24 h. A landmark set of five trials in 2015 provided a foundation upon which years of incremental follow-ups, meta-analyses and new breakthroughs would be built. With optimized devices for thrombectomy and image analysis, the neurointerventional community has turned to workflow and systemization in this new era of acute ischemic stroke treatment. The aim of this review is to chronicle the evidence in the epoch of positive trials, synthesize ancillary studies to these, and discuss the imminent challenges that remain.

Quantitative measurement of vascular density and flow using optical coherence tomography angiography (OCTA) in patients with central retinal vein occlusion: Can OCTA help in distinguishing ischemic from non-ischemic type?

Background

To evaluate microvascular changes and quantitative parameters in patients with central retinal vein occlusion (CRVO) by using optical coherence tomography angiography (OCTA) and finding difference between presumably ischemic and non ischemic CRVO.

Methods

Patients with CRVO (31) and healthy control (20) were enrolled in this observational case control study. The OCTA was done for each patient and control subject. In macular area 2 images were taken for each eye (3 × 3 mm and 8 × 8 mm). The images were analyzed at three capillary plexuses (superficial and deep retinal capillary layers and choriocapillaris layer).

Results

Thirty-one patients with CRVO (mean age 60.00 ± 13.72 years) and 20 healthy age/gender matched subjects (mean age 54.10 ± 12.33 years) were enrolled in this study (p = 0.095). The mean visual acuity of patients was 0.47 ± 0.54 LogMAR. Eyes with CRVO as compared with fellow eyes and control group showed significant reduction of flow in superficial (1.171 ± 0.262 vs. 1.362 ± 0.285 vs. 1.453 ± 0.105) and deep capillary plexus (1.042 ± 0.402 vs. 1.331 ± 0.315 vs. 1.526 ± 0.123) and choriocapillaris (1.206 ± 0.543 vs. 1.841 ± 0.308 vs. 1.966 ± 0.05) and vascular density in superficial (45.92 ± 4.2 vs. 50.99 ± 4.35 vs. 52.85 ± 2.99) and deep (48.03 ± 4.71 vs. 55.86 ± 3.81 vs. 58.2 ± 2.65) capillary plexuses. Some parameters (flow of both retinal capillary plexuses and parafoveal vascular density in deep plexus) showed significantly reduction in fellow eyes than control group. The parameters including flow [superficial (1.014 ± 0.264 vs. 1.279 ± 0.19) and deep (0.873 ± 0.442 vs. 1.152 ± 0.32) capillary plexuses and choriocapillaris (0.79 ± 0.327 vs. 1.424 ± 0.51)] and vascular density [superficial (44.24 ± 2.13 vs. 46.58 ± 4.13) and deep (45.28 ± 3.5 vs. 49.32 ± 3.94) capillary plexuses] were lower significantly in ischemic type than non ischemic CRVO. The most damaged parameter was flow in deep capillary plexus. The model with smallest Akaike information criterion and Bayesian information criterion was chosen as the best model. For easier calculation, we also calculated the reduced model. By choosing the threshold of 12.6, the formula [3.9 × F_1S + 0.8 × F_3S] can diagnose the presumably ischemic CRVO from non ischemic type with AUC of 0.84, sensitivity of 100% and specificity of 69%. (F_1S: flow in the central 1 mm-radius-circle of superficial plexus and F_3S: flow in the central 3 mm-radius-circle of superficial plexus).

Conclusion and relevance

In CRVO patients, the OCTA can accurately evaluate changes in microvascular structures. It may help in differentiation ischemic CRVO from non-ischemic CRVO.

In-Hospital Pediatric Stroke Alert Activation

BACKGROUND

Pediatric stroke alerts or "code strokes" allow for rapid evaluation, imaging, and treatment of children presenting with stroke-like symptoms. In a previous study of emergency department-initiated pediatric stroke alerts, 24% of children had confirmed strokes. The purpose of this study was to characterize in-hospital pediatric stroke alerts.

METHODS

Demographic and clinical information was obtained from a quality improvement database and medical records for children (zero to 20 years) at a single institution for whom a stroke alert was activated after hospital admission between April 2011 and December 2016. Stroke alert activation criteria included a new focal neurological defect occurring within 48 hours. A neurologist evaluated the patient within 15 minutes and rapid magnetic resonance imaging was available.

RESULTS

Medical personnel activated in-hospital stroke alerts for 56 children (median age 6.5 years, interquartile range 1 to 13, 52% male). Stroke was the final diagnosis of 25 (45%), 72% ischemic, and 28% hemorrhagic strokes. Other diagnoses included neurological urgencies: seizure (21%), posterior reversible encephalopathy syndrome (7%), transient ischemic attack (5%), and acute disseminated encephalomyelitis (4%). Of the stroke diagnoses, 68% were stroke alerts called in the pediatric intensive care unit or pediatric cardiac intensive care unit. Rapid neuroimaging was completed in 91%; magnetic resonance imaging brain was the first image in 55%.

CONCLUSIONS

Of in-hospital pediatric stroke alerts, 45% were stroke while 38% were other neurological conditions requiring urgent evaluation. In-hospital stroke alerts were commonly activated for children with complicated medical histories. Rapid neurological evaluation facilitated care. No child underwent thrombolysis or thrombectomy.

NBCe1 Na+-HCO3- cotransporter ablation causes reduced apoptosis following cardiac ischemia-reperfusion injury in vivo

AIM

To investigate the hypothesis that cardiomyocyte-specific loss of the electrogenic NBCe1 Na⁺-HCO₃^- cotransporter is cardioprotective during in vivo ischemia-reperfusion (IR) injury.

METHODS

An NBCe1 (Slc4a4 gene) conditional knockout mouse (KO) model was prepared by gene targeting. Cardiovascular performance of wildtype (WT) and cardiac-specific NBCe1 KO mice was analyzed by intraventricular pressure measurements, and changes in cardiac gene expression were determined by RNA Seq analysis. Response to in vivo IR injury was analyzed after 30 min occlusion of the left anterior descending artery followed by 3 h of reperfusion.

RESULTS

Loss of NBCe1 in cardiac myocytes did not impair cardiac contractility or relaxation under basal conditions or in response to β-adrenergic stimulation, and caused only limited changes in gene expression patterns, such as those for electrical excitability. However, following ischemia and reperfusion, KO heart sections exhibited significantly fewer apoptotic nuclei than WT sections.

CONCLUSION

These studies indicate that cardiac-specific loss of NBCe1 does not impair cardiovascular performance, causes only minimal changes in gene expression patterns, and protects against IR injury in vivo .

Association between the EPHX2 p.Lys55Arg polymorphism and prognosis following an acute coronary syndrome

Inhibition of soluble epoxide hydrolase (sEH, EPHX2) elicits potent cardiovascular protective effects in preclinical models of ischemic cardiovascular disease (CVD), and genetic polymorphisms in EPHX2 have been associated with developing ischemic CVD in humans. However, it remains unknown whether EPHX2 variants are associated with prognosis following an ischemic CVD event. We evaluated the association between EPHX2 p.Lys55Arg and p.Arg287Gln genotype with survival in 667 acute coronary syndrome (ACS) patients. No association with p.Arg287Gln genotype was observed (P = 0.598). Caucasian EPHX2 Arg55 carriers (Lys/Arg or Arg/Arg) had a significantly higher risk of 5-year mortality (adjusted hazard ratio [HR] 1.61, 95% confidence interval [CI] 1.01-2.55, P = 0.045). In an independent population of 2712 ACS patients, this association was not replicated (adjusted HR 0.92, 95% CI 0.70-1.21, P = 0.559). In a secondary analysis, Caucasian homozygous Arg55 allele carriers (Arg/Arg) appeared to exhibit a higher risk of cardiovascular mortality (adjusted HR 2.60, 95% CI 1.09-6.17). These results demonstrate that EPHX2 p.Lys55Arg and p.Arg287Gln polymorphisms do not significantly modify survival after an ACS event. Investigation of other sEH metabolism biomarkers in ischemic CVD appears warranted.

Risk factor profile and anatomic features of previously asymptomatic patients presenting with carotid-related stroke

OBJECTIVE

Although carotid atherosclerotic-mediated stroke remains a major cause of morbidity and mortality, some have suggested intervention in carotid stenosis should be limited to symptomatic patients given the advances in medical therapy. The present study was conducted to assess the atherosclerotic risk factor profiles, anatomic features, and clinical outcomes of previously asymptomatic patients admitted with stroke of carotid etiology.

METHODS

We reviewed the data from 3382 patients admitted to a tertiary referral center with an ischemic stroke during 2005 to 2015. We focused on patients admitted with a radiographically confirmed infarct ipsilateral to a documented carotid artery stenosis ≥50%, with the admitting neurology team adjudicating the stroke etiology as carotid related. Patients were excluded if they had had a previous transient ischemic attack, previous infarct ipsilateral to any carotid lesion, or previous carotid revascularization, intracranial hemorrhage, or malignancy. Patient demographic data, medical treatments before stroke, stroke admission carotid imaging, and stroke treatments and outcomes were assessed.

RESULTS

A total of 219 carotid stroke patients (7% of all strokes) were identified, of whom 61% were white and 66% were men, with a mean age of 68 ± 12 years. Hypertension (79%) and smoking (33% current; 29% former) were predominant risk factors. On admission, 50% were receiving antiplatelet therapy (aspirin, n = 92 [41%]; clopidogrel, n = 9 [4%]; dual therapy, n = 11 [5%]) and 55% were receiving lipid-lowering agents (statin, n = 115 [53%]; other, n = 6 [2%]); 77 patients (35%) were receiving both antiplatelet and lipid-lowering therapy. Of the 219 patients, 156 (71%) presented with a moderate or severe stroke (National Institutes of Health stroke scale ≥5 at admission), 54 (25%) received lytic therapy, 96 (43%) presented with an occluded ipsilateral internal carotid artery, and 117 (53%) ultimately underwent carotid revascularization at a median of 4 days. Individuals receiving both antiplatelet and lipid-lowering therapy were significantly less likely to experience a moderate or severe stroke (44% vs 78%; P = .006).

CONCLUSIONS

Internal carotid artery occlusion is the culprit lesion in 43% of carotid-related strokes in those without previous symptoms. Previously asymptomatic patients not receiving combined antiplatelet and lipid-lowering medical therapy presenting with carotid-related stroke are significantly more likely to experience a severe, debilitating stroke. However, those receiving appropriate risk-reduction medical therapy are still at risk of carotid-mediated stroke. These results suggest medical therapy alone is unlikely to be sufficient stroke prevention for patients with significant carotid stenosis.

Systolic characteristics and dynamic changes of the mitral valve in different grades of ischemic mitral regurgitation - insights from 3D transesophageal echocardiography

BACKGROUND

Mitral regurgitation in ischemic heart disease (IMR) is a strong predictor of outcome but until now, pathophysiology is not sufficiently understood and treatment is not satisfying. We aimed to systematically evaluate structural and functional mitral valve leaflet and annular characteristics in patients with IMR to determine the differences in geometric and dynamic changes of the MV between significant and mild IMR.

METHODS

Thirty-seven patients with IMR (18 mild (m)MR, 19 significant (moderate+severe) (s)MR) and 33 controls underwent TEE. 3D volumes were analyzed using 3D feature-tracking software.

RESULTS

All IMR patients showed a loss of mitral annular motility and non-planarity, whereas mitral annulus dilation and leaflet enlargement occurred in sMR only. Active-posterior-leaflet-area decreased in early systole in all three groups accompanied by an increase in active-anterior-leaflet-area in early systole in controls and mMR but only in late systole in sMR.

CONCLUSIONS

In addition to a significant enlargement and loss in motility of the MV annulus, patients with significant IMR showed a spatio-temporal alteration of the mitral valve coaptation line due to a delayed increase in active-anterior-leaflet-area. This abnormality is likely to contribute to IMR severity and is worth the evaluation of becoming a parameter for clinical decision-making. Further, addressing the leaflets aiming to increase the active leaflet-area is a promising therapeutic approach for significant IMR. Additional studies with a larger sample size and post-operative assessment are warranted to further validate our findings and help understand the dynamics of the mitral valve.

Clinical analysis of combined revascularization in treating ischemic Moyamoya disease in adults

OBJECTIVE

The aim of this study was to investigate the clinical efficacy of superficial temporal artery-middle cerebral artery anastomosis (STA-MCA)+encephalo-duro-myo-synangiosis (EDMS) in treating ischemic Moyamoya disease (IMD) in adults.

METHODS

A total of 30 adult patients with IMD were selected to be included in the study; they underwent STA-MCA+EDMS and were followed up for 3 months to 2 years. The digital subtraction angiography findings, modified Rankin scale (mRs) score, and complications of all the patients were compared.

RESULTS

Thirty patients successfully completed the surgery. Three patients had postoperative complications (two patients with cerebral infarction on the surgical side and one patient with poor scalp healing). The postoperative morbidity rate was 10%. Angiography conducted at 3 to 6 months postoperatively showed 28 cases of anastomotic patency; the anastomotic patency rate was 93.3%. The mRs scores of the patients' neurological function 3 months after surgery were lower than those before surgery.

CONCLUSION

STA-MCA+EDMS is effective in treating Moyamoya disease.

An Experimental Study on Repeated Brief Ischemia in Promoting Sciatic Nerve Repair and Regeneration in Rats

BACKGROUND

Research has shown that ischemic preconditioning reduced the severity of ischemia-reperfusion injury in brain in rats, we have a hypothesis that repeated brief ischemia has positive effects on peripheral nerve damage. This study was conducted to investigate the potential protective effects of repeated brief ischemia on peripheral nerve regeneration using a rat model of experimental sciatic nerve transection injury.

METHODS

Treatment groups (groups A-D) received repeated, brief ischemia every 1 day/2 days/3 days/7 days. After surgery for 4, 8, 12 weeks, we evaluated sciatic functional index test, gastrocnemius muscle wet mass, axon and nerve fiber diameter, density, G-ratio, immunohistochemistry of S-100, vascular endothelial growth factor (VEGF), and the ultrastructure of the nerves.

RESULTS

Sciatic functional index test and muscle wet mass were improved on the repeated brief ischemia groups. Ischemia treatment resulted in a significant increase in axon and nerve fiber density as well as S-100 and VEGF-positive cell, which indicated that repeated brief ischemia promotes Schwann cell proliferation and reconstruction.

CONCLUSIONS

This study exhibits the positive effects of repeated brief ischemia in sciatic nerve transection injury, possibly in part because it can improve VEGF and the physiologic state of Schwann cells in the ischemic environment and then accelerate the ability of neurite outgrow.

Neonatal Encephalopathy in Calves Presented to a University Hospital

BACKGROUND

While studies have examined bovine dystocia in relation to calf survival, little has been published regarding perinatal morbidity and treatment of newborn calves beyond failure of transfer of passive immunity (FTPI). Neonatal encephalopathy (NE) is a clinical syndrome commonly diagnosed in infants and foals but is poorly described in calves.

HYPOTHESIS/OBJECTIVES

To identify risk factors for development of NE in calves and factors predictive of survival.

ANIMALS

Neonatal calves presented to a University hospital over a 10-year period.

METHODS

Retrospective cohort study (2005-2015). Medical records of all neonatal calves presented to the hospital were examined, and cases of NE were identified. Data pertaining to demographics, dam parity, labor, treatment, and outcome were collected and analyzed with univariate and multivariate statistics.

RESULTS

Of 200 calves in the final analysis, 58 (29%; 95% CI: 22.8-35.8%) were classified as NE and 142 calves as non-NE. In univariate analysis, factors significantly associated with diagnosis of NE included male sex, presence of dystocia, abnormal position in the birth canal, and prolonged labor. In the multivariate model, only orientation of the calf in the birth canal remained significant (OR 2.14; 95% CI: 1.02-4.49; P = 0.044). Overall survival of calves with NE was good (45/58; 77.6%; 95% CI: 64.7-87.5); dam parity and being a twin was significantly associated with nonsurvival.

CONCLUSIONS

Calves born after dystocia, especially if malpresented, should be closely monitored for nursing behavior within the first 24 hours of life. Prognosis for survival is good, but supportive care might be required for several days.

Diffusion-Weighted MRI Stroke Volume Following Recanalization Treatment is Threshold-Dependent

PURPOSE

Infarct lesion segmentation has been problematic as there are a wide range of relative and absolute diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) thresholds that have been used for this purpose. We examined differences of stroke lesion volume and evolution evaluated by magnetic resonance imaging (MRI) during the immediate post-treatment phase (<5 h) and at 24 h.

METHODS

In this study 33 acute ischemic stroke patients were imaged with MRI <5 h and 24 h post-reperfusion treatment. Lesion volumes were segmented on ADC maps and average DWI using literature cited absolute ADC and relative DWI thresholds. The segmented lesion volumes within both time points were compared and the absolute change in lesion volume (infarct growth) between the two time points was calculated and compared using Bland-Altman analysis.

RESULTS

Lesion volumes differed significantly when different relative DWI or absolute ADC thresholds were used (p < 0.05), which held true for baseline as well as follow-up lesions. The median absolute changes in lesion volume from baseline to follow-up for ADC thresholds of 550 × 10^-6 mm²/s, 600 × 10^-6 mm²/s, 630 × 10^-6 mm²/s and 650 × 10^-6 mm²/s were 3.5 ml, 4.2 ml, 4.5 ml, and 6.5 ml, respectively (p < 0.05). Likewise, the median absolute changes in lesion volume from baseline to follow-up for DWI thresholds, k = 0.85, 1.28, 1.64, 1.96, and 2.7 were 10.1 ml, 7.3 ml, 5.7 ml, 5.4 ml and 4.2 ml, respectively (p < 0.05).

CONCLUSION

Absolute lesion volumes and changes in lesion volumes (infarct growth) measured after recanalization treatment were dependent on absolute ADC and relative DWI thresholds, which may have clinical significance. Standardization of techniques for measuring DWI lesion volumes requires immediate attention.

Renal impairment in stroke patients: A comparison between the haemorrhagic and ischemic variants

Background: Renal impairment is regularly seen in hospitalized stroke patients, affecting the outcome of patients, as well as causing difficulties in their management. A prospective cohort study was conducted to assess the trend of renal function in hospitalized ischemic and haemorrhagic stroke patients. The incidence of renal impairment in these subgroups, the contributing factors and the need for renal replacement in renal impaired patients was evaluated. Methods: Alternate day renal function testing was performed in hospitalized stroke patients. Estimated glomerular filtration rate (e-GFR) was calculated and the trend of renal function in the two stroke subgroups (haemorrhagic and ischemic) was assessed, with renal impairment defined as e-GFR < 60mL/ minute per 1.73m 2. Results: Among 52 patients, 25 had haemorrhagic stroke (mean age 59.81 ± 14.67) and 27 had ischemic stroke (mean age 56.12 ± 13.08). The mean e-GFR (mL/minute per 1.732m 2) at admission in the haemorrhagic stroke subgroup was 64.79 ± 25.85 compared to 86.04 ± 26.09 in the ischemic stroke subgroup (p=0.005). Sixteen out of 25 (64%) patients in the haemorrhagic stroke subgroup and 9 out of 27 (33.3%) patients in the ischemic subgroup developed renal impairment (p=0.27). The location of the bleed (p=0.8), volume of hematoma (p=0.966) and surgical intervention (p=0.4) did not predispose the patients to renal impairment. One out of 16 patients with haemorrhagic stroke (who eventually died), and 2 out of 9 patients with ischemic stroke required renal replacement. Conclusion: Renal impairment is commonly seen in stroke patients, more so in patients who suffered haemorrhagic strokes.  The impairment, however, is transient and rarely requires renal replacement therapy.