Bilateral vertebral artery dissection and infratentorial stroke complicated by stress-induced cardiomyopathy

Outcomes following surgical and endovascular treatment of extracranial vertebral artery aneurysms (VAA): a systematic evaluation of the literature

Extracranial vertebral artery aneurysms are rare complications resulting from trauma and multiple different diseases. However, the difference between clinical and surgical profiles is well understood. To investigate the clinical and interventional outcomes following extracranial vertebral artery aneurysms (VAA) treatment through a systematic review of the literature to date, an electronic database search for full-text English articles was conducted following PRISMA guidelines. The search yielded results on clinical and surgical outcomes for extracranial VAAs. These results included patient-specific risk factors, indications, and techniques. Our literature search resulted in 561 articles, of which 36 studies were qualified to be included in the analysis. A total of 55 patients with multiple various extracranial VAA incidents were included. The mean age of subjects was 42 years (ranging from 13.0 to 76.0 years), and the majority of patients were males (71%, n =39). Blunt trauma was the most frequent risk factor for extracranial VAA formation (35%, n = 19). The majority of aneurysms (60%) were dissected in nature. The most common form of treatment for extracranial VAAs was the use of a flow diverter (24%, n=13). Overall, five (9%) patients had long-term adverse neurological complications following intervention with 5% (n=3) mortality, 2% (n=1) resulting in unilateral vocal cord paralysis, and 2% (n=1) resulted in a positive Romberg sign. The mortality rate is 15.7% in the surgical group, whereas the endovascular treatment did not result in any mortality. The endovascular approach is a safe and effective treatment of extracranial VAAs due to its relatively low overall complication rate and lack of resulting mortality. This is in contrast to the surgical approach which results in a higher rate of complications, recurrence, and mortality outcomes. An understanding of the factors and clinical outcomes associated with the incidence of extracranial VAAs is essential for the future improvement of patient outcomes.

Long-Term Outcomes of Stenting on Non-Acute Phase Extracranial Supra-Aortic Dissections

Objective

Methods

Results

Conclusion

Reversible stress cardiomyopathy in Guillain-Barré syndrome: a case report

Background

Case Presentation

Conclusions

Vertebral Artery Dissection and Takotsubo Syndrome Associated with Marijuana Use

Cervical artery dissection is an intimal tear in a cervical artery with the development of intramural hematoma resulting in stenosis, occlusion, or aneurysmal dilation. Takotsubo syndrome (TTS) is characterized by acute heart failure with a distinctive regional left ventricular contraction profile. We presented the case of a 33-year-old male who visited the emergency department due to right-sided arm/leg weakness, slurred speech and transient loss of right eye vision. The patient was diagnosed with vertebral artery dissection and TTS complicated with community-acquired pneumonia. Only other case has been reported of TTS with bilateral vertebral artery dissection. TTS is a disease triggered by physical or emotional stressors. It can be confused with acute myocardial infarction and should be disoriented for the appropriate management. The prognosis is generally favorable.

Short-term remote ischemic conditioning may protect monkeys after ischemic stroke

Objective

We aimed to evaluate the safety and effectiveness of short-term remote ischemic postconditioning (RIPC) in acute stroke monkey models.

Methods

Acute stroke monkeys were allocated to four groups based on the number of limbs exposed to RIPC. RIPC was initiated by 5-min cuff inflation/deflation cycles of the target limb(s) for 5-10 bouts. Vital signs, skin integrity, brain MRI, and serum levels of cardiac enzymes (myoglobin, creatine kinase [CK], CK-muscle/brain [CK-MB]), one inflammatory marker (high-sensitivity C-reactive protein [hsCRP], and one endothelial injury marker (von Willebrand factor [vWF]) were assessed. Spetzler scores were used to assess neurological function.

Results

No significant differences in vital signs or local skin integrity were found. Short-term RIPC did not reduce infarct volume under any condition at the 24th hour after stroke. However, neurological function improved in multi-limb RIPC compared with sham and single-limb RIPC at the 30th day follow-up after stroke. Myoglobin, CK, and CK-MB levels were reduced after multi-limb RIPC, regardless of the number of bouts. Moreover, multi-limb RIPC produced a greater diminution in CK-MB levels, whereas two-limb RIPC was more effective in reducing serum CK levels at the 24th hour after stroke. hsCRP increased after 5 bouts of multi-limb RIPC before decreasing below baseline and single-limb RIPC levels. Serum vWF was decreased at later time points after RIPC in all RIPC groups.

Conclusions

Stroke monkeys in hyperacute stage may benefit from short-term RIPC; however, whether this intervention can be translated into clinical use in patients with acute ischemic stroke warrants further study.

Takotsubo syndrome in a stroke patient with carotid artery stenosis

Takotsubo syndrome (TTS) is a transient transient left ventricular dysfunction, predominantly affecting elderly women and often preceded by emotional or physical stress. TTS may be the cause as well as the consequence of stroke. We report a 82-years old female with a history of long-standing untreated arterial hypertension who was hospitalized because of a left-sided tongue paralysis and dysarthria. Cerebral magnetic resonance imaging showed ischemic lesions in the territory of the right middle cerebral artery affecting the capsula interna and gyrus praecentralis. The carotid and cerebral arteries showed extensive atherosclerotic wall irregularities, a high-grade stenosis of the M1-segment of the right middle cerebral artery and a 60% stenosis of the internal carotid artery at its origin. Elevated creatine-kinase and Pro-brain-natriuretic peptide levels and development of new ischemic signs in the electrocardiogram suggested myocardial infarction, although the patient did not complain about cardiac symptoms. Echocardiography showed apical ballooning which resolved during the following days. The patient refused coronary angiography why the diagnosis of TTS was not completely established. However, normalization of echocardiogram and ECG were indicative for TTS.

TTS has to be considered in stroke patients, irrespective of their etiology. Since patients often do not report typical symptoms or may even be asymptomatic, TTS can be overlooked. If the ECG in stroke patients shows signs of myocardial ischemia, troponin and BNP levels should be measured whose ratio may even help to differentiate between TTS and myocardial infarction. Echocardiography, coronary angiography and follow-up investigations are needed to confirm the diagnosis of TTS.

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Takotsubo syndrome (TTS) affects predominantly elderly women and is often preceded by emotional or physical stress.

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TTS has to be considered in stroke patients, irrespective of their etiology.

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Since stroke patients often do not report typical symptoms or may even be asymptomatic TTS can be overlooked.

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If the ECG in stroke patients shows signs of myocardial ischemia, troponin and BNP levels should be measured whose ratio may even help to differentiate between TTS and myocardial infarction.

Takotsubo Syndrome: Clinical Features, Pathogenesis, Treatment, and Relationship with Cerebrovascular Diseases

PURPOSE OF REVIEW

This review paper aims to provide a complete and updated overview on the clinical and pathophysiological aspects of Takotsubo syndrome (TTS), including prognosis, therapy, and the association with cerebrovascular conditions.

RECENT FINDINGS

TTS is an increasingly recognized non-ischemic cardiomyopathy characterized by sudden, temporary weakening of the myocardium, of which the pathogenesis is unknown. Although pathogenesis of TTS remains unclear, a complex interaction between catecholamine-mediated stimulation, myocardial stunning, and subsequent stress-related myocardial dysfunction seems to be the main pathophysiological mechanism. Stroke is linked to TTS by a dual relationship since it may induce TTS by catecholamine release even if TTS itself also may be complicated by left ventricular thrombi leading to stroke. Given its possible complications, including the association with neurological diseases, both cardiologist and neurologists should be aware about TTS in order to diagnose it promptly and to initiate appropriate therapeutic measures.

Endovascular Stenting of Extracranial Carotid and Vertebral Artery Dissections: A Systematic Review of the Literature

BACKGROUND:

Carotid and vertebral artery dissections are a leading cause of stroke in young individuals.

OBJECTIVE:

To examine the published safety and efficacy of endovascular stenting for extracranial artery dissection.

METHODS:

We conducted a systematic review of the literature to identify all cases of endovascular management of extracranial carotid and vertebral artery dissections.

RESULTS:

For carotid dissections, our review yielded 31 published reports including 140 patients (153 vessels). Reported etiologies were traumatic (48%, n = 64), spontaneous (37%, n = 49), and iatrogenic (16%, n = 21). The technical success rate of stenting was 99%, and the procedural complication rate was 1.3%. Mean angiographic follow-up was 12.8 months (range, 2-72 months) and revealed in-stent stenosis or occlusion in 2% of patients. Mean clinical follow-up was 17.7 months (range, 1-72 months), and neurological events were seen in 1.4% of patients. For vertebral artery dissections, our review revealed 8 reports including 10 patients (12 vessels). Etiologies were traumatic (60%, n = 6), spontaneous (20%, n = 2), and iatrogenic (20%, n = 2). There was a 100% technical success rate. The mean angiographic follow-up period was 7.5 months (range, 2-12 months). No new neurological events were reported during a mean clinical follow-up period of 26.4 months (range, 3-55 months).

CONCLUSION:

Endovascular management of extracranial arterial dissection continues to evolve. Current experience shows that this treatment option is safe and technically feasible. Prospective randomized trials compared with medical management are needed to further elucidate the role of stenting.

Apical ballooning resulting from limbic encephalitis

BACKGROUND

Neurogenic stunned myocardium is an increasingly recognized cause of left ventricular apical ballooning, or takotsubo cardiomyopathy. We report the first case of neurogenic stunned myocardium as a result of limbic encephalitis.

METHODS

This 73-year-old woman with anterograde and retrograde amnesia was investigated using electrocardiography, magnetic resonance imaging, and left ventricular angiography.

RESULTS

Electrocardiography showed deep T-wave inversions in multiple leads, magnetic resonance imaging demonstrated increased signal on fluid-attenuated inversion recovery images symmetrically within the medial temporal lobes consistent with limbic encephalitis. Left ventricular angiography showed apical ballooning.

CONCLUSIONS

Because the insula has extensive interconnections with limbic structures, limbic encephalitis could lead to alterations in the sympathetic regulation of the insular cortex resulting in neurogenic stunned myocardium.