Simultaneous acute cardio-cerebral infarction: is there a consensus for management?

Cardiocerebral Infarction Presenting in a Neurosurgical Emergency: A Case Report and Literature Review

Cardiocerebral infarction (CCI), the simultaneous occurrence of acute ischemic stroke and acute myocardial infarction (AMI), is a rare but critical condition. However, the optimal treatment strategy, particularly regarding the use of tissue plasminogen activator (t-PA), remains unclear. This case report describes a patient with CCI diagnosed during a neurosurgical emergency. A 67-year-old man with a history of hypertension presented with sudden right hemiparesis and sensory aphasia 30 minutes prior to hospital arrival. Diffusion-weighted magnetic resonance imaging revealed acute cerebral infarction in the left middle cerebral artery territory but without large-vessel occlusion. Routine electrocardiography (ECG) showed ST-T elevation in leads V1, V2, II, III, and aVF (augmented vector foot). Subsequent blood tests confirmed positive troponin T and elevated creatine kinase levels. Despite the absence of reported AMI symptoms, the patient received a diagnosis of CCI. Due to the uncertain time of AMI onset and to expedite transfer to the percutaneous coronary intervention (PCI) unit, t-PA administration was withheld. Upon transfer, dual antiplatelet therapy with aspirin (200 mg) and clopidogrel (300 mg) was initiated. Emergency coronary angioplasty successfully treated a 99% stenosis of the left anterior descending artery (#7). The patient's post-procedure course was uneventful. After 18 days, he was transferred to a rehabilitation hospital with a modified Rankin Scale score of 3. This case highlights the importance of routine 12-lead ECG in neurosurgical emergencies, regardless of presenting symptoms like chest pain. While guidelines support the use of t-PA in CCI, its administration requires careful consideration due to specific risks, including cardiac rupture and limitations on antithrombotic therapy within the first 24 hours.

Concurrent Cardio-Cerebral Infarction - A Case Report and Literature Review

Concurrent cardio-cerebral infarction (CCI) describes the simultaneous occurrence of an acute myocardial infarction and an acute ischemic stroke. It is a rare phenomenon, and no consensus yet exists on how to best treat it. CCI patients present with variable clinical scenarios and complications which makes the establishment of a treatment guideline difficult. We present here a case of a 67-year-old male with concurrent acute ST-elevation myocardial infarction and acute ischemic stroke due to right middle cerebral artery occlusion who was successfully treated with Tenecteplase and mechanical thrombectomy. A literature review was also conducted in search of potential reasonable management strategies of CCI.

The Simultaneous Occurrence of Acute ST-Elevation Myocardial Infarction, Acute Ischemic Stroke, and Pulmonary Embolism

Acute ST-elevation myocardial infarction (STEMI), acute ischemic stroke (AIS), and acute pulmonary embolism (PE) are life-threatening conditions, each posing a high risk of morbidity and mortality. When all three of these acute conditions occur simultaneously, the overall prognosis for the patient becomes considerably worse. We report a case of a 70-year-old woman who presented to the emergency department (ED) with a triad of acute STEMI, AIS, and PE as a consequence of atherosclerotic heart disease, atrial fibrillation, and a prolonged transatlantic flight. The diagnoses were promptly confirmed through emergent coronary and cerebral angiography, along with a computerized tomography pulmonary angiogram (CTPA). The patient underwent a combination of medical therapy and endovascular thrombectomy. However, she later developed a subarachnoid hemorrhage and eventually progressed to brain death.

Use of Diterpene Ginkgolides Meglumine Injection to Regulate Plasma Levels of PAI-1 and t-PA in Patients With Acute Atherosclerotic Cerebral Infarction

BACKGROUND

To: (i) explore the effect of diterpene ginkgolides meglumine injection (DGMI) on neurological deficit symptoms in acute atherosclerotic cerebral infarction (AACI) patients; (ii) measure the level of plasma plasminogen activator inhibitor (PAI)-1 and tissue plasminogen activator (t-PA).

METHODS

Eighty AACI patients were divided equally and randomly into the DGMI group and control group. In addition to basic treatment, the DGMI group was treated with DGMI (25 mg/d) for 14 days. The control group had basic treatment without DGMI. Before and after treatment, the degree of neurological deficit was assessed, thromboelastography undertaken, and plasma levels of PAI-1 and t-PA measured.

RESULTS

The National Institutes of Health Stroke Scale score of patients in the DGMI group after treatment was lower than that in the control group, and the Barthel Index was higher than that in the control group ( P <0.05). Thromboelastography revealed that, in the DGMI group, the R value and K value after treatment were higher than before treatment, the angle and maximum amplitude value were lower than before treatment, and both were significant ( P <0.05). Compared with the control group, the plasma PAI-1 level of patients in the DGMI group was lower than that in the control group, and the t-PA level was higher than that in the control group ( P <0.05) after 14 days of treatment.

CONCLUSIONS

DGMI may affect the activity of the blood coagulation and fibrinolysis system by regulating the plasma level of PAI-1 and t-PA, and improving neurological deficit symptoms. DGMI is important for improving the prognosis of patients with AACI.

Endovascular therapy for cardiocerebral infarction associated with atrial fibrillation: A case report and literature review

Background:

Cardiocerebral infarction (CCI) is a rare entity that refers to the simultaneous occurrence of acute myocardial infarction and acute ischemic stroke. The management of CCI patients remains unclear.

Case Description:

An 86-year-old woman with a medical history of paroxysmal atrial fibrillation presented with a sudden onset of consciousness disturbance and right hemiplegia. Computed tomography of the head revealed no intracranial hemorrhage but the left hyperdense middle cerebral artery sign, associated with ST-segment elevation in II, III, and aVF noted on a routine 12-lead electrocardiogram at admission. The patient was immediately brought to the catheterization laboratory and percutaneous coronary intervention (PCI) was performed first, followed by mechanical thrombectomy, resulting in successful revascularization of the both diseases.

Conclusion:

Although the treatment strategy of CCI may depend on the condition of coronary and cerebral ischemia, it may be appropriate to prioritize coronary angiography and PCI if not acute ischemic stroke is critical.

SARS-COV-ATE risk assessment model for arterial thromboembolism in COVID-19

Patients with SARS-CoV-2 infection are at an increased risk of cardiovascular and thrombotic complications conferring an extremely poor prognosis. COVID-19 infection is known to be an independent risk factor for acute ischemic stroke and myocardial infarction (MI). We developed a risk assessment model (RAM) to stratify hospitalized COVID-19 patients for arterial thromboembolism (ATE). This multicenter, retrospective study included adult COVID-19 patients admitted between 3/1/2020 and 9/5/2021. Among 3531 patients from the training cohort, 15.5% developed acute in-hospital ATE, including stroke, MI, and other ATE, compared to 13.4% in the validation cohort. The 16-item final score was named SARS-COV-ATE (Sex: male = 1, Age [40–59 = 2, > 60 = 4], Race: non-African American = 1, Smoking = 1 and Systolic blood pressure elevation = 1, Creatinine elevation = 1; Over the range: leukocytes/lactate dehydrogenase/interleukin-6, B-type natriuretic peptide = 1, Vascular disease (cardiovascular/cerebrovascular = 1), Aspartate aminotransferase = 1, Troponin-I [> 0.04 ng/mL = 1, troponin-I > 0.09 ng/mL = 3], Electrolytes derangement [magnesium/potassium = 1]). RAM had a good discrimination (training AUC 0.777, 0.756–0.797; validation AUC 0.766, 0.741–0.790). The validation cohort was stratified as low-risk (score 0–8), intermediate-risk (score 9–13), and high-risk groups (score ≥ 14), with the incidence of ATE 2.4%, 12.8%, and 33.8%, respectively. Our novel prediction model based on 16 standardized, commonly available parameters showed good performance in identifying COVID-19 patients at risk for ATE on admission.

Post-operative neutrophil-to-lymphocyte ratio and outcome after thrombectomy in acute ischemic stroke

Background

Neutrophil to lymphocyte ratio (NLR) is a novel inflammatory marker to predict adverse cardiovascular events. However, there is a lack of data on hemorrhagic transformation (HT) and neurological outcome after mechanical thrombectomy in acute ischemic stroke (AIS). We investigated whether NLR before and after thrombectomy for patients with AIS was associated with HT and neurological outcomes.

Methods

We performed a retrospective analysis of consecutive patients with anterior circulation AIS who underwent thrombectomy. HT was evaluated by CT within 24 h after thrombectomy. Clinical data had been collected retrospectively; laboratory data were extracted from our electronic hospital information system. NLR was obtained at admission (NLR1) and immediately after thrombectomy (NLR2). The main outcomes were post-interventional intracranial hemorrhage and unfavorable functional status (modified Rankin scale scores of 3–6) 3 months post-stroke.

Results

A total of 258 patients with AIS, according to the NIHSS (median 14), were included. NLR2 was higher in patients who developed HT after thrombectomy and unfavorable neurological outcomes 3 months post-stroke (p < 0.001) than in those without HT or favorable outcomes, even after correction for co-factors [Odds Ratio (OR) 1.35 for HT, 95% confidence interval (CI)1.16–1.57, p < 0.001, and 1.85 for unfavorable outcome, 95%CI 1.57–2.17, p < 0.001]. The optimal cutoff value for the NLR2 as an indicator for auxiliary diagnosis of HT and the unfavorable outcome was 8.4 and 8.8, respectively.

Conclusion

NLR immediately after thrombectomy is a readily available biomarker of HT and neurological outcomes in patients with AIS.

Simultaneous cardio-cerebral infarction: a meta-analysis

BACKGROUND/INTRODUCTION

Cardio-cerebral infarction (CCI), which involves the simultaneous occurrence of acute ischaemic stroke and acute myocardial infarction, has a reported incidence of 0.0009%. Treatment of CCI presents a dilemma to physicians as both conditions are time critical. Despite the need for standardized treatment protocols, published data are sparse.

AIM

We aimed to summarize the reported cardio-cerebral infarction cases in the literature.

DESIGN

Meta-analysis.

METHODS

Four databases, Pubmed, Embase, Scopus and Google Scholar were searched until 25 August 2020. A title and abstract sieve, full-text review and extraction of data were conducted independently by three authors.

RESULTS

A total of 44 cases of CCI were identified from 37 case reports and series; 15 patients (34.1%) were treated using percutaneous coronary intervention (PCI) with stent, 8 patients (18.2%) were treated with a PCI without stent, 10 patients (22.7%) were treated via a cerebral vessel thrombectomy and 8 patients (18.2%) were treated via a thrombectomy of a coronary vessel. For medications, 20 patients (45.5%) were treated with thrombolytics, 10 patients (22.7%) were treated with anticoagulants, 8 patients (18.2%) were treated with antiplatelets and 11 patients (25.0%) were treated with anticoagulants and antiplatelets. Of 44 patients, 10 patients died, and 9 of those were due to cardiac causes. Among the 44 patients, days to death was observed to be a median of 2.0 days (interquartile range (IQR): 1.5, 4.0). The modified Rankin Score was measured in nine patients, with a median score of 2.0 (IQR: 1.0, 2.5) being reported.

DISCUSSION/CONCLUSION

The condition of CCI has substantial morbidity and mortality, and further studies are needed to examine the optimal diagnostic and treatment strategies of these patients.

Lower uric acid level may be associated with hemorrhagic transformation after intravenous thrombolysis

BACKGROUND

Previous studies have shown that uric acid (UA) is a powerful water-soluble antioxidant and free radical scavenger for humans. However, the relationship between serum uric acid (SUA) and hemorrhagic transformation (HT) is still controversial. To address this challenge, we aimed to explore the association between serum UA and HT in patients with acute ischemic stroke (AIS) after intravenous thrombolysis (IVT).

METHODS

A retrospective analysis was conducted in patients with anterior circulation AIS who underwent IVT at Affiliated Hospital of Qingdao University from 2016 to 2021. HT was evaluated by CT or MRI within 7 days after admission. Baseline demographic, clinical, and laboratory data were compared between the HT and non-HT groups, and between different types of HT groups which were documented according to the European Cooperative Acute Stroke Study III Classification (ECASS III).

RESULTS

A total of 727 AIS patients were enrolled, including 112 patients who experienced HT (HT group) and 615 patients who did not experience HT (non-HT group). Patients with HT had significantly lower UA levels compared to those without HT (253.65 ± 97.75 vs 315.97 ± 96.42, p < 0.001); however, there was no significant difference for UA levels in different types of HT (p = 0.907). After adjusting confounders, patients in the fourth UA quartile showed a significant decrease in HT compared with those in the first quartile (OR 0.266, 95% CI 0.107-0.661, p = 0.006). The best cutoff value was identified as 218.5 μmol/L after analysis.

CONCLUSIONS

These findings suggest that low levels of UA may be associated with HT after IVT.

Depletion of mmu_circ_0001751 (circular RNA Carm1) protects against acute cerebral infarction injuries by binding with microRNA-3098-3p to regulate acyl-CoA synthetase long-chain family member 4

Circular RNAs (circRNAs) play a critical role in acute cerebral infarction (ACI). Our research discussed the effect of circ-Carm1 in ACI and its potential molecular mechanisms. Healthy controls and patients with ACI were included in this study. The establishment of an oxygen and glucose deprivation/reoxygenation (OGD/R) model of HT22 cells was conducted to mimic ACI in vitro. Quantitative reverse transcription polymerase chain reaction was conducted to determine mRNA levels extracted from serum and HT22 cell samples, and Western blotting was performed to determine protein levels. Terminal deoxynucleotidyl transferase dUTP nick end labeling and cell counting kit 8 assays were conducted to evaluate cellular functions. Concentrations of Fe²⁺ and malondialdehyde, and levels of transferrin receptor 1, glutathione peroxidase 4, and glutathione were evaluated to determine ferroptosis in OGD/R-induced HT22 cells. The binding relationships between mRNAs and miRNAs were verified. circ-Carm1 was highly expressed in OGD/R-treated HT22 cells. Deficiency of circ-Carm1 restored cell viability and suppressed ferroptosis in OGD/R-induced HT22 cells. miR-3098-3p was predicted to be a target of circ-Carm1. The miR-3098-3p inhibitor partly neutralized the functions of circ-Carm1 in OGD/R-induced HT22 cells. Furthermore, acyl-CoA synthetase long-chain family member 4 (ACSL4) was confirmed to be a downstream target of miR-3098-3p and was elevated in OGD/R-induced HT22 cells. Overexpression of ACSL4 mitigated the functions of miR-3098-3p and accelerated HT22 cell dysfunction. Hence, circ-Carm1 is upregulated in ACI. circ-Carm1 suppression protects HT22 cells from dysfunction by inhibiting ferroptosis. Therefore, inducing circ-Carm1 deficiency may be a promising therapeutic method for ACI.

Which one to do first?: a case report of simultaneous acute ischemic stroke and myocardial infarction

Background: Although there are common risk factors for acute ischemic stroke and myocardial infarction, simultaneous onset of both diseases is uncommon. Here, we present a case of acute cerebral infarction with concurrent fatal myocardial infarction. Case Report: A 54-year-old man presented with left hemiparesis, gaze preponderance to the right side, and visual and tactile extinction. Computed tomography angiography showed occlusion of the right middle cerebral artery. ST-elevation myocardial infarction was suspected on electrocardiography. After the injection of intravenous tissue plasminogen activator, thrombectomy was attempted first, and the coronary angiogram was planned after recanalization of the cerebral artery. However, thrombectomy was discontinued because of cardiac arrest. Despite extracorporeal membrane oxygenation and emergency percutaneous coronary intervention, the patient died of multiorgan failure.Conclusion: Double primary acute ischemic stroke and myocardial infarction are rare but may be fatal due to the narrow therapeutic time window for both diseases. Careful consideration of the urgency of cardiac status is essential.

Successful endovascular treatment of simultaneous acute ischaemic stroke and hyperacute ST-elevation myocardial infarction: the first case report of a single-operator cardio-cerebral intervention

Background

The simultaneous management of cardio-cerebral infarctions is an extremely difficult task, as both organs need to receive reperfusion therapy in a limited time to avoid death or permanent disability. The following case is the first published endovascular treatment of synchronous heart and brain infarctions delivered by a single operator with excellent clinical outcome.

Case summary

A 67-year-old female patient was directly transported to the emergency room of a comprehensive stroke centre with acute onset global aphasia and right hemiplegia. The onset to admission time exceeded the 4.5-h time window of systemic thrombolysis. Head computed tomography (CT) excluded extensive early extensive brain damage, CT angiography documented left middle cerebral artery occlusion and mechanical thrombectomy was indicated. Extensive anterior ST elevation was detected on the transport monitor while waiting for in-hospital transfer. The two simultaneously evolving pathologies were handled in a single endovascular procedure that took less than 60 min by a dual-trained interventional cardiologist/neurointerventional surgeon. The patient recovered without any major cardiac or neurologic sequela.

Discussion

Interventional cardiologists, professionally trained through a neurointerventional fellowship programme to perform endovascular stroke interventions according to the latest multi-society position paper, could not only complement stroke teams lacking manpower, but their unique experience could also help the patients suffering from the most devastating forms of cardio-cerebral infarctions.

Eight-and-a-half syndrome: a rare presentation

Eight-and-a-half syndrome is a rare entity characterised by conjugate horizontal gaze palsy, ipsilateral internuclear ophthalmoplegia and ipsilateral lower motor neuron type facial palsy. It is due to a lesion affecting median longitudinal fasciculus, paramedian pontine reticular formation and facial nerve fascicle on the same side at the level of pons. The diagnosis is easily missed as it needs detailed ocular movement examination. It is mainly caused due to infarction or demyelinating conditions. We are reporting an interesting case of a 54-year-old man with right-side eight-and-a-half syndrome due to acute ischaemic stroke and ST-elevation myocardial infarction of the inferior wall.

Hemodynamic Stroke in Simultaneous Cardio Cerebral Infarction: A New Term for Cardiologist

We report an uncommon case of simultaneous cardio-cerebral infarction, due to Inferior – right ventricle ST Segment Elevation Myocardial Infarction (STEMI) with acute ischemic stroke. Incidence of cardio cerebral infarction is exceptionally rare, with an incidence rate as low as 0.009%. Hemodynamic compromise in patients with acute myocardial infarction may result in the cerebral blood flow reduction that cause hemodynamic stroke. Due to the rarity of this condition, there were no recommended therapeutics strategy. Mechanical reperfusion with PCI procedure may be a superior choice in the settings of acute cardio-cerebral infarction for restoring hemodynamic stability.

Cardiocerebral Infarction: A Single Institutional Series

OBJECTIVES

Cardiocerebral infarction (CCI) is the rare occurrence of acute ischemic stroke (AIS) and acute myocardial infarction (AMI), either at the same time (simultaneous or synchronous) or one after the other (metachronous). The aim of this study is to describe the clinical profile, management and treatment outcomes of patients with CCI.

MATERIALS AND METHODS

This is a 3-year cross-sectional study of patients with CCI describing their clinical presentation, management, and outcomes. The primary outcome measures were all-cause mortality and functional outcome measured with the modified Rankin Scale score (mRS) at discharge and at 30 days post-CCI. We also described the frequency of major and minor hemorrhagic events.

RESULTS

Out of 1683 AIS patients and 1983 AMI patients admitted during our time period, 29 patients fulfilled the inclusion criteria (mean age 60 ±12, 79% males, median admission NIHSS 16 [range 1-26]). Of these, 20 (69%) had metachronous CCI while 9 (31%) had synchronous CCI. Most of the patients were given antithrombotics and only 14% were given reperfusion therapies. The all-cause mortality is 45% and 69% of which were cardiovascular deaths. Seventeen and 21% of CCI patients had a good functional outcome on discharge and at 30 days from CCI onset respectively. A total of 8 (28%) patients had hemorrhagic events.

CONCLUSIONS

We present the largest single institutional series showing the prevalence rate of cardiocerebral infarction to be 0.79% (0.55% for metachronous, 0.25% for synchronous), with patients presenting as moderate-severe acute ischemic strokes and high-risk acute myocardial infarction. These patients have a high mortality rate with a significant proportion having cardiovascular deaths.

Simultaneous cardio-cerebral infarction in the coronavirus disease pandemic era: A case series

INTRODUCTION

Simultaneous occurrence of acute ischemic stroke and myocardial infarction is reported to have variable precipitating causes. This occurrence has been rarely reported in the literature and described only in very few case reports. During the surge of coronavirus disease (COVID-19) in our region, we noted an increase in the simultaneous occurrence of cardio-cerebral infarction. This led us to explore the possible mechanisms and pathophysiology that could contribute to this increase. The retrospective nature of the study limited us from drawing any conclusion about causation. Rather, we aimed to formulate a hypothesis for future, more rigorous studies.

PATIENT CONCERNS

We present an overview of 5 cases of simultaneous cardio-cerebral infarction that we encountered in our emergency department within 1 month.

DIAGNOSIS

In all cases, diagnosis was confirmed using an electrocardiogram, assessment of laboratory cardiac markers, and imaging.

INTERVENTIONS

In all cases, dual antiplatelet therapy was started and thrombolysis was held, as the condition was considered high risk in most of the patients. Cardiac catheterization lab was not activated either because the patient was unstable or the risk of COVID-19 in staff outweighed the benefit added in patient treatment.

OUTCOMES

Two out of 5 patients died because of early complications that lasted for few days. The remaining 3 were discharged from the hospital in moderate functionality for extensive therapy and rehabilitation.

CONCLUSION

Early recognition and immediate treatment is important in different scenarios leading to thrombosis as the outcome. Additionally, addressing the unknown risks that could contribute to our traditional understanding of these causative mechanisms is important. The hypothesis of exacerbated damage caused by inflammatory and immunological endothelial systemic damage should further be explored to be able to delineate new possibilities in managing these conditions.

Temporal Trends, Predictors, and Outcomes of Acute Ischemic Stroke in Acute Myocardial Infarction in the United States

Background

There are limited contemporary data prevalence and outcomes of acute ischemic stroke (AIS) complicating acute myocardial infarction (AMI).

Methods and Results

Adult (>18 years) AMI admissions using the National Inpatient Sample database (2000–2017) were evaluated for in‐hospital AIS. Outcomes of interest included in‐hospital mortality, hospitalization costs, length of stay, discharge disposition, and use of tracheostomy and percutaneous endoscopic gastrostomy. The discharge destination was used to classify survivors into good and poor outcomes. Of a total 11 622 528 AMI admissions, 183 896 (1.6%) had concomitant AIS. As compared with 2000, in 2017, AIS rates increased slightly among ST‐segment–elevation AMI (adjusted odds ratio, 1.10 [95% CI, 1.04–1.15]) and decreased in non–ST‐segment–elevation AMI (adjusted odds ratio, 0.47 [95% CI, 0.46–0.49]) admissions (P<0.001). Compared with those without, the AIS cohort was on average older, female, of non‐White race, with greater comorbidities, and higher rates of arrhythmias. The AMI‐AIS admissions received less frequent coronary angiography (46.9% versus 63.8%) and percutaneous coronary intervention (22.7% versus 41.8%) (P<0.001). The AIS cohort had higher in‐hospital mortality (16.4% versus 6.0%; adjusted odds ratio, 1.75 [95% CI, 1.72–1.78]; P<0.001), longer hospital length of stay, higher hospitalization costs, greater use of tracheostomy and percutaneous endoscopic gastrostomy, and less frequent discharges to home (all P<0.001). Among AMI‐AIS survivors (N=153 318), 57.3% had a poor functional outcome at discharge with relatively stable temporal trends.

Conclusions

AIS is associated with significantly higher in‐hospital mortality and poor functional outcomes in AMI admissions.

Sequential butylphthalide therapy combined with dual antiplatelet therapy in the treatment of acute cerebral infarction

OBJECTIVE

To observe the clinical efficacy of sequential butylphthalide therapy combined with dual antiplatelet therapy in the treatment of elderly patients with acute cerebral infarction (ACI).

METHODS

One hundred and twenty-two elderly patients with ACI who were admitted to the department of neurology of our hospital at May 2016-August 2018 were selected grouped into a control group and an observation group by random number table method, 61 in each group. On the basis of conventional treatment, the patients in the control group were given dual antiplatelet therapy (aspirin enteric-coated tablets + clopidogrel bisulfate tablets), while the patients in the observation group were given sequential butylphthalide therapy on the basis of the control group. The clinical effects of the two groups were compared after four weeks of treatment, and the changes of National Institutes of Health Stroke Scale (NIHSS), ADL score, plasma 3-mercaptopyruvate sulphurtransferase (3-MST) and Amyloid β42 (Aβ42) levels and the occurrence of adverse reactions during treatment were recorded.

RESULTS

The clinical efficacy of the observation group was better than that of the control group (P<0.05). There was no significant difference in NIHSS and ADL scores between the two groups before treatment (P>0.05). After treatment, the NIHSS and ADL scores of the observation group were better than those of the control group (P<0.05). There was no significant difference in plasma levels of 3-MST and AB42 between the two groups before treatment (P>0.05). The level of plasma 3-MST in the observation group was higher than that in the control group, and the level of plasma Aβ42 was lower than that in the control group (P<0.05). No serious adverse reactions occurred during the treatment period in both groups.

CONCLUSION

Butylphthalide sequential therapy combined with dual antiplatelet therapy is effective in the treatment of elderly ACI. It can effectively improve the plasma level of 3-MST and decrease the plasma level of Aβ42, which is conducive to improving the living ability and neurological function of patients and has high safety.

Association between neurological deterioration and outcomes in patients with stroke

Background

Neurological deterioration (ND) shortly after stroke is common in Chinese patients. We aimed to determine the effects of ND during hospitalization on stroke prognosis.

Methods

We retrospectively reviewed files from the stroke registry of the Department of Neurology of Tianjin Huanhu Hospital between October 1, 2008, and December 31, 2015. The inclusion criteria were: age ≥18 years, diagnosis of acute ischemic stroke, and first-ever ischemic stroke occurring within 7 days prior to admission. ND was defined as an increase in the National Institutes of Health Stroke Scale (NIHSS) score by ≥4 points during hospitalization. Early neurological deterioration (END) was defined as an increase in the NIHSS score by ≥4 points between the baseline and 48-hour evaluations. Late neurological deterioration (LND) was defined as an increase in the NIHSS score by ≥4 points between the 48-hour and discharge evaluations. Multivariate regression was used to evaluate the relationship between early and late ND and short- and long-term outcomes. Primary and secondary outcomes based on the modified Rankin scale (mRS) were evaluated at 3 months and 1 year. Favorable and poor outcomes were defined as mRS scores of 0-2 and ≥3, respectively.

Results

A total of 9,650 patients were included. ND occurred in 293 patients (3.0%) during hospitalization. Among them, 192 (65.5%) were in the END group, and 101 (34.5%) were in the LND group. After adjusting for age, gender, and NIHSS scores, END was a significant independent predictor of poor outcome at both 3 months (primary outcome OR 8.069, secondary outcome OR 8.194) and 1 year (primary outcome OR 7.895, secondary outcome OR 5.679). The same pattern was seen in the LND group (3 months primary outcome OR 7.608, secondary outcome OR 6.349, 1-year primary outcome OR 10.793, secondary outcome OR 5.245).

Conclusions

ND during hospitalization, regardless of whether it occurs in the early or late period after stroke, is an independent predictor of poor prognosis.

Endovascular Therapy for Concurrent Cardio-Cerebral Infarction in a Patient With Trousseau Syndrome

Only a few patients have been reported to undergo endovascular therapy for Trousseau syndrome. This is the first report of a patient with Trousseau syndrome who developed synchronous cardiocerebral infarction and underwent endovascular therapy for both. A 55-year-old woman with Trousseau syndrome arising from stage IV ovarian cancer presented with consciousness disturbance, aphasia, and right hemiparesis. Magnetic resonance imaging showed acute cerebral infarction limited to the left basal ganglia and occlusion of the left middle cerebral artery (MCA). Electrocardiography showed ST elevation in leads II, III, and aVF with reciprocal change. Mild elevation of myocardial enzymes was observed in laboratory data. She was diagnosed with synchronous cardiocerebral infarction. Both infarctions were considered as appropriately indicated for endovascular therapy. Since her vital signs were stable, a decision was made to treat the cerebral infarction first. Thrombectomy with a stent retriever was performed, which achieved complete recanalization of the left MCA. Percutaneous coronary intervention successfully recanalized the occluded right coronary artery. She suffered no recurrence of stroke or acute coronary syndrome upon heparin administration. Cardiocerebral infarction caused by Trousseau syndrome is rare and demands optimal planning of endovascular therapy.

Simultaneous Acute Anterior ST-Elevation Myocardial Infarction and Acute Ischemic Stroke of Left Middle Cerebral Artery: A Case Report

BACKGROUND Acute ST-elevation myocardial infarction and acute ischemic stroke are both life-threatening conditions with high risk for morbidity and mortality without timely intervention. This simultaneous event has been reported to be as rare as 0.009%. The treatments of both conditions individually have been well documented in the literature and guidelines, but when presenting concomitantly, it poses a unique therapeutic challenge. Immediate treatment of one condition can delay management or even have deleterious effects on the other condition. CASE REPORT We present the case of a 41-year-old female with simultaneous acute anterior ST-elevation myocardial infarction and acute left middle cerebral artery ischemic stroke. Due to a low National Institute of Health score she was not a candidate for endovascular treatment and received alteplase per acute ischemic stroke protocol with delayed percutaneous coronary intervention. She was eventually discharged to a long-term acute care facility for continued rehabilitation. CONCLUSIONS The co-existence of ST elevation myocardial infarction and acute ischemic stroke is rare, but when these 2 common conditions present simultaneously, it provides a unique therapeutic challenge. Although infrequent, this challenging scenario deserves more recognition and a discussion among the medical community.