Size, shape and location of lacunar strokes and correlation with risk factors

A rare fatal cerebral fat emboli syndrome with large vessel occlusion post femur fracture plating in an older female: A case report

INTRODUCTION AND IMPORTANCE

Cerebral fat embolism syndrome is a rare complication of long bone fractures, often overlooked and found in late stages. We present patient with a late recognition of Cerebral Fat Embolism with Large vessel occlusion post femoral internal fixation.

CASE PRESENTATION

An elderly female suffered right intertrochanteric fracture after falling down. Open reduction internal fixation with Interlocking plate was performed at the fifth day. Upon returning to the ward, the patient did not regain full consciousness and apparent right hemiparesis were observed. A head Computed Tomography was performed and found left hemisphere ischemia consistent with middle cerebral artery occlusion. The patient condition worsened and died 3 days postoperatively.

CLINICAL DISCUSSION

Cases of fat embolism that occur purely isolated in the brain are rare cases that occur after internal fixation of the femur, so they are often not noticed by clinicians. Several factors can increase the risk of the event, delay in fixation and diabetes mellitus which was found in our patient could increase the risk of fat emboli syndrome. Apart from that, osteoporosis also increases the risk of fat embolism syndrome that was found in our subject.

CONCLUSIONS

Cerebral Large Vessel Occlusion Fat Embolism Syndrome is rare case occur following internal fixation. There is a need for early recognition to be carried out to treat early or prevent the occurrence of fat embolism.

Long-term outcomes among ischemic stroke TOAST subtypes: A 12-year Cohort study in China

BACKGROUND

Disparities in short-term ischemic stroke (IS) prognosis among Trial of Org 10172 in Acute Stroke Treatment (TOAST) subtypes were observed. Notably, little is known about the long-term prognosis of different subtypes in China. We aim to investigate the long-term outcome in IS patients and try to explore the potential interactive effects between IS subtypes and antithrombotic therapy.

METHODS

This is a prospective cohort of stroke survivors. Patients diagnosed with first-ever IS at the Department of Neurology, West China Hospital, Sichuan University from January 2010 to December 2019 were recruited. They were followed until September 2022 to assess recurrence, mortality, and functional recovery. The multivariate Fine-Gray model assessed stroke recurrence, while Cox regression estimated hazard ratios. Modified Rankin Scale scores(mRS) were analyzed using the generalized linear mixed effects model.

RESULTS

At baseline, 589 of 950 participants (62.00 %) were male. The longest follow-up was 150 months, the shortest was 1.5 months, and the median follow-up was 81.0 months. Cardio-embolism (CE) bore the highest mortality risk compared to large artery atherosclerosis (LAA) (HR=4.43,95 %CI 1.61-12.23). Among survivors on anticoagulant therapy, CE exhibited a reduced risk of mortality (HR = 0.18, 95 % CI 0.04-0.80). In function recovery, small artery occlusion (SAO) demonstrated more favorable prognostic outcomes (β=-2.08, P<0.01, OR=0.13,95 %CI 0.03-0.47). Among survivors taking antiplatelet drugs, SAO demonstrated a slower pace of functional recovery compared to LAA (β=1.39, P=0.05, OR=3.99,95 %CI 1.01-15.74).

CONCLUSIONS

Long-term outcomes post-first IS vary among TOAST subtypes. Anticoagulant therapy offers long-term benefits among patients of the CE. However, prolonged administration of antiplatelet drugs among SAO patients may be limited in improving function recovery. Physicians should carefully consider treatment options for different IS subtypes to optimize patient outcomes and stroke care effectiveness.

Frailty and outcomes in lacunar stroke

BACKGROUND

Lacunar strokes (LS) are ischemic strokes of the small perforating arteries of deep gray and white matter of the brain. Frailty has been associated with greater mortality and attenuated response to treatment after stroke. However, the effect of frailty on patients with LS has not been previously described.

OBJECTIVE

To analyze the association between frailty and outcomes in LS.

METHODS

Patients with LS were selected from the National Inpatient Sample (NIS) 2016-2019 using the International Classification of Disease, 10^th edition (ICD-10) diagnosis codes. The 11-point modified frailty scale (mFI-11) was used to group patients into severely frail and non-severely frail cohorts. Demographics, clinical characteristics, and complications were defined. Health care resource utilization (HRU) was evaluated by comparing total hospital charges and length of stay (LOS). Other outcomes studied were discharge disposition and inpatient death.

RESULTS

Of 48,980 patients with LS, 10,830 (22.1%) were severely frail. Severely frail patients were more likely to be older, have comorbidities, and pertain to lower socioeconomic status categories. Severely frail patients with LS had worse clinical stroke severity and increased rates of complications such as urinary tract infection (UTI) and pneumonia (PNA). Additionally, severe frailty was associated with unfavorable outcomes and increased HRU.

CONCLUSION

Severe frailty in LS patients is associated with higher rates of complications and increased HRU. Risk stratification based on frailty may allow for individualized treatments to help mitigate adverse outcomes in the setting of LS.

Post-stroke Cognition at 1 and 3 Years Is Influenced by the Location of White Matter Hyperintensities in Patients With Lacunar Stroke

Lacunar strokes are a common type of ischemic stroke. They are known to have long-term cognitive deficits, but the influencing factors are still largely unknown. We investigated if the location of the index lacunar stroke or regional WMH and their change at 1 year could predict the cognitive performance at 1 and 3 years post-stroke in lacunar stroke patients. We used lacunar lesion location and WMH-segmented data from 118 patients, mean age 64.9 who had a brain MRI scan soon after presenting with symptoms, of which 88 had a repeated scan 12 months later. Premorbid intelligence (National Adult Reading Test) and current intelligence [Addenbrooke's Cognitive Exam-Revised (ACE-R)] were measured at 1, 12, and 36 months after the stroke. ANCOVA analyses adjusting for baseline cognition/premorbid intelligence, vascular risk factors, age, sex and total baseline WMH volume found that the recent small subcortical infarcts (RSSI) in the internal/external capsule/lentiform nucleus and centrum semiovale did not predict cognitive scores at 12 and 36 months. However, RSSI location moderated voxel-based associations of WMH change from baseline to 1 year with cognitive scores at 1 and 3 years. WMH increase in the external capsule, intersection between the anterior limb of the internal and external capsules, and optical radiation, was associated with worsening of ACE-R scores 1 and 3 years post-stroke after accounting for the location of the index infarct, age and baseline cognition.