TGR5 signalling in heart and brain injuries: focus on metabolic and ischaemic mechanisms

The heart and brain are the core organs of the circulation and central nervous system, respectively, and play an important role in maintaining normal physiological functions. Early neuronal and cardiac damage affects organ function. The relationship between the heart and brain is being continuously investigated. Evidence-based medicine has revealed the concept of the "heart- brain axis," which may provide new therapeutic strategies for certain diseases. Takeda protein-coupled receptor 5 (TGR5) is a metabolic regulator involved in energy homeostasis, bile acid homeostasis, and glucose and lipid metabolism. Inflammation is critical for the development and regeneration of the heart and brain during metabolic diseases. Herein, we discuss the role of TGR5 as a metabolic regulator of heart and brain development and injury to facilitate new therapeutic strategies for metabolic and ischemic diseases of the heart and brain.

Systematic review and presentation of a single center series

INTRODUCTION

Ischemic priapism is a medical emergency that, if not treated, could lead to permanent erectile dysfunction. The association between cocaine and priapism is well-known; however, data on patient characteristics, treatment, and outcomes is missing. This work aimed to answer the research question: What are the characteristics, management strategies, and erectile prognosis of patients consuming cocaine and presenting with priapism?

METHODS

We conducted a systematic review according to PRISMA guidelines and described our case series.

RESULTS

Eight studies were selected for qualitative synthesis, presenting information on ten patients. In our case series, we showed information regarding four patients. From the systematic review, the mean presentation time was 42.6 h, and the mean number of procedures to solve priapism was 2,4; in our case series was 42.75 h and 2, respectively.

CONCLUSION

Cocaine-related priapism might present with a delayed diagnosis, need more procedures to be managed, and have a worse prognosis. More extensive and prospective studies are required.

Frequency & factors associated with elevated lipoprotein-a among Ghanaian stroke survivors

BACKGROUND

Indigenous Africans are genetically predisposed to elevated lipoprotein-a (Lp(a)), a veritable risk factor for ischemic stroke. Recent studies have demonstrated the promising efficacy of therapeutic interventions for addressing elevated Lp(a) among patients at high risk of atherosclerotic cardiovascular events. It is important to assess the burden of elevated Lp(a) among stroke survivors of African ancestry aimed at addressing potential unmet therapeutic gaps for optimal secondary prevention.

PURPOSE

To assess the frequency of elevated lipoprotein-a among Ghanaian stroke survivors and factors associated with it.

METHODS

A prospective study conducted at the Neurology clinic of the Komfo Anokye Teaching Hospital among ischemic stroke survivors aged ≥18 years. Serum lipoprotein-a concentrations were measured using ELISA kits. A multivariate regression analysis was fitted to identify factors independently associated with elevated lipoprotein-a concentration > 30 mg/dl.

RESULTS

Among 116 stroke survivors, 35 (30.2%) had elevated Lp(a). The adjusted odds ratio (95% CI) of factors associated with elevated Lp(a) were female sex 3.09 (1.05-9.12), p = 0.04, diabetes mellitus 3.52 (1.32-9.40), p = 0.01, urban dwelling 4.64 (1.61-13.39), p = 0.005 and total cholesterol 1.85 (1.28-2.67), p = 0.001. Whereas the LDL cholesterol significantly decreased from baseline to month 12 among a subset of participants, the Lp(a) levels significantly increased from a baseline value of 29.38 ± 15.32 mg/dl to 40.97 ± 29.72 mg/dl, p = 0.032.

CONCLUSION

Approximately 1 in 3 Ghanaian ischemic stroke survivors harbor an elevated Lp(a) associated with female sex, urban residence, diabetes mellitus and raised cholesterol. This burden highlights an unmet therapeutic gap in secondary risk reduction in this resource-limited setting.

Challenges to Thrombolysis in A Resource-Poor Setting- A Case Report

A major complication of acute ischemic stroke is death and disability. The emergence of reperfusion therapy in form of thrombolysis and endovascular thrombectomy has led to the reversal of this trend in high-income countries. Low- and middle-income countries are yet to benefit maximally from these time-bound treatment options due to some limitations. We intend to highlight some of these in this report. We report an 80-year-old male patient with hypertension and firstdegree AV block admitted 3 hours after the onset of stroke with National Institutes of Health Stroke Scale (NIHSS) score of 13 and Medical Research Council (MRC) muscle power grade 3 in both the left upper and lower limb. Urgent non-contrast brain CT revealed no evidence of hemorrhage. Intravenous tissue plasminogen activator (tPA) was administered at a dose of 0.6 mg/kg 9 hours after symptom onset. He made significant improvement afterward and was discharged. The challenges encountered in his management include prehospital and intrahospital delay, and unavailability of tissue plasminogen activator. There is a need for an improved healthcare delivery system in order to reduce the morbidity associated with acute ischemic stroke.

Do Triglyceride-Rich Lipoproteins Equal Low-Density Lipoproteins in Risk of ASCVD?

PURPOSE OF REVIEW

Recent large clinical trials have failed to show that triglyceride-rich lipoprotein-lowering therapies decrease the risk of atherosclerotic cardiovascular disease (ASCVD). In this review, we reconcile these findings with evidence showing that elevated levels of triglyceride-rich lipoproteins and the cholesterol they contain, remnant cholesterol, cause ASCVD alongside low-density lipoprotein (LDL) cholesterol.

RECENT FINDINGS

Results from observational epidemiology, genetic epidemiology, and randomized controlled trials indicate that lowering of remnant cholesterol and LDL cholesterol decrease ASCVD risk by a similar magnitude per 1 mmol/L (39 mg/dL) lower non-high-density lipoprotein cholesterol (remnant cholesterol+LDL cholesterol). Indeed, recent guidelines for ASCVD prevention recommend the use of non-high-density lipoprotein cholesterol instead of LDL cholesterol. Current consensus is moving towards recognizing remnant cholesterol and LDL cholesterols as equals per 1 mmol/L (39 mg/dL) higher levels in the risk assessment of ASCVD; hence, triglyceride-rich lipoprotein-lowering therapies should also lower levels of non-HDL cholesterol to reduce ASCVD risk.

Association of electrocardiographic and echocardiographic variables with neurological outcomes after ischemic Stroke

Background

Cardiac dysfunction is often seen following neurological injury. Data regarding cardiac involvement after ischemic stroke is sparse. We investigated the association of electrocardiographic (ECG) and echocardiographic variables with neurological outcomes after an acute ischemic stroke.

Methods

We retrospectively collected baseline characteristics, stroke location, National Institute of Health Stroke Scale (NIHSS) at the time of admission, acute reperfusion treatment, ECG parameters, and echocardiographic data on 174 patients admitted with acute ischemic stroke. Outcomes of the stroke were based on cerebral performance category (CPC) with a CPC score of 1-2 indicating a good outcome and a CPC score of 3-5 indicating a poor outcome.

Results

Older age (75.31 ± 11.89 vs. 65.16 ± 15.87, p < 0.001, OR = 1.04, 95 % CI 1.01-1.07), higher heart rate (80.63 ± 18.69 vs. 74.45 ± 17.17 bpm, p = 0.024, OR = 1.02, 95 % CI 1.00-1.05) longer QTc interval (461.69 ± 39.94 vs. 450.75 ± 35.24, p = 0.024, OR = 1.01, 95 % CI 0.99-1.02), NIHSS score (60.9 % vs. 17.8 %, p < 0.001, OR = 14.90, 95 % CI 3.83-69.5), and thrombolysis (15 % vs. 5 %, p = 0.049, OR = 0.55, 95 % CI 0.10-2.55) were associated with poor neurological outcomes. However, when adjusted for age and NIHSS, heart rate and QTc were no longer statistically significant. None of the other ECG and echocardiographic variables were associated neurological outcomes.

Conclusions

Elevated heart rate and longer QTc intervals may potentially predict poor neurological outcomes. Further studies are needed for validation and possible integration of these variables in outcome predicting models.

Perinatal hypoxic-ischemic brain injury: What's behind the "ribbon effect"?

Ribbon effect describes a perceived macroscopic color reversal of the gray and white matter, characterized by a pale cortex and diffusely dusky underlying white matter. This finding is thought to be unique to the perinatal period and indicative of hypoxic-ischemic injury. However, the clinical and microscopic correlates of this macroscopic finding have not been clearly defined. A 21-year retrospective study of autopsies was performed. Ribbon effect was seen in 190 subjects, ages 20 weeks gestation to 9.5 months adjusted age. Clinical associations and radiographic findings were similar in ribbon effect cases and controls. A variety of histologic findings were observed including acute neuronal injury, diffuse white matter gliosis, and white matter necrosis. Only white matter vascular congestion was significantly correlated to the macroscopic severity of ribbon effect; the severity of white matter injury and acute neuronal injury were not significantly correlated to ribbon effect. While hypoxic-ischemic changes were present in nearly all cases of ribbon effect, the location, severity, and chronicity of these changes varied considerably, and similar findings were observed in controls. The presence of ribbon effect therefore does not predict microscopic findings apart from vascular congestion, highlighting the importance of microscopic examination in perinatal brain autopsies.

Stroke: Hospital Nursing Management Within the First 24 Hours

Within the United States, someone will have a stroke approximately every 40 seconds. Eighty-five percent of strokes are ischemic, with 15% classified as either intracranial or subarachnoid hemorrhage. Stroke care is complex, and nurses play a critical role in identification, assessment, management, and coordination throughout the stroke continuum of care. This article will explore the nursing care of the patient with ischemic and hemorrhagic stroke during the first 24 hours.

Mechanical Thrombectomy for Pediatric Large Vessel Occlusions : A Systematic Review and Meta-analysis

BACKGROUND

Acute intracranial large vessel occlusion (LVO) is an important cause of morbidity and mortality among children; however, unlike in adults, no clinical trial has investigated the benefit of mechanical thrombectomy (MT) in pediatric LVO. Thus, MT remains an off-label procedure for pediatric stroke.

PURPOSE

To investigate the efficacy and safety of MT in pediatric LVO.

METHODS

A systematic literature search was conducted in Ovid MEDLINE, Ovid Embase, Scopus, Web of Science, and Cochrane Central Register of Clinical Trials databases. Studies reporting safety and efficacy outcomes for endovascular treatment of pediatric LVO were included. Data regarding recanalization, functional outcome, symptomatic intracranial hemorrhage (sICH), and mortality were extracted from the included studies. Functional outcome was assessed with the modified Rankin scale (mRS). A fixed or random-effects model was used to calculate pooled event rates and 95% confidence intervals (CI).

RESULTS

In this study 11 studies comprising 215 patients were included. The successful recanalization rate was 90.3% (95% CI = 85.77-95.11%), and complete recanalization was achieved in 52.7% (95% CI = 45.09-61.62%) of the cases. The favorable (mRS = 0-2) and excellent (mRS = 0-1) outcome rates were 83.3% (95% CI = 73.54-94.50%) and 59.5% (95% CI = 44.24-80.06%), respectively. The overall sICH prevalence was 0.59% (95% CI = 0-3.30%) and mortality rate was 3.2% (95% CI = 0.55-7.38%).

CONCLUSION

In our meta-analysis, MT demonstrated a promising safety and efficacy profile for pediatric patients, with consistently high efficacy outcomes and low complication rates. Our results support the utilization of MT in pediatric LVOs; however, prospective studies are still needed to further establish the role of pediatric MT as a first-line treatment strategy.

Postoperative vasospasm and cerebral infarction in a patient with large pituitary adenoma and cerebral superficial siderosis

BACKGROUND

Cerebral vasospasm and infarction are rare complications of transsphenoidal surgery for pituitary adenoma. Cerebral superficial siderosis may result from subarachnoid hemorrhage from a pituitary adenoma. The constellation of cerebral superficial siderosis, cerebral vasospasm, and pituitary adenoma is rare. We describe an extremely rare clinical constellation of immediately postoperative cerebral vasospasm and consequent cerebral infarction in a case with a large pituitary adenoma and cerebral superficial siderosis.

CASE DESCRIPTION

A 70-year-old man presented with a pituitary adenoma causing a worsening headache. Preoperative magnetic resonance (MR) images revealed cerebral superficial siderosis, suggesting subarachnoid hemorrhage from pituitary apoplexy. MR angiography (MRA) showed no vasospasm. During the transsphenoidal surgery, an intratumoral hematoma was found. The arachnoid membrane was partially torn and intratumoral hematoma entered the subarachnoid space. Intraoperatively, the intracranial vessels remained intact. The suprasellar tumor was almost entirely resected; however, the patient remained comatose postoperatively. Computed tomography revealed ischemic lesions in the bilateral insular and frontotemporal cortex. MRA revealed cerebral vasospasm in the bilateral middle cerebral arteries. The patient was treated with levetiracetam for nonconvulsive status epilepticus and underwent a lumbar peritoneal shunt surgery for secondary hydrocephalus. However, the patient remained listless.

CONCLUSION

Postoperative cerebral vasospasm and infarction are severe but rare complications for a pituitary adenoma after transsphenoidal surgery. Preoperative and intraoperative subarachnoid hemorrhage might have been a risk factor in our case. Similar cases should be warranted to analyze whether cerebral superficial siderosis may also indicate the risk of severe postoperative vasospasm immediately after transsphenoidal surgery for pituitary adenoma.

Multi-Organ System Screening, Care, and Patient Support in Systemic Sclerosis

Systemic sclerosis (SSc) is a heterogenous systemic autoimmune disease of complex multi-organ manifestations with a disease-specific mortality of >50%. The patient journey is fraught with severe, diverse, and diffuse physical impairment, psychological burden, and diminishing health-related quality of life. SSc remains unfamiliar to many clinicians. Delayed/misdiagnosis, inadequate screening, and attention for common complications with potentially preventable disability/death contribute to patients feeling isolated and unsupported. We present actionable standards including screening, anticipatory guidance, and counseling in patient-centered SSc-care emphasizing psycho-social health as the central goal, whereas robust vigilance and efforts to improve biophysical health and survival are imperatives that support this goal.

Higher mold levels found in in the deteriorated housing in the Sun Valley neighborhood of Denver, Colorado compared to other Denver housing and higher rates of health insurance claims for some diseases documented for the Sun Valley residents compared to other Denver residents

The Sun Valley Homes public housing in Denver, Colorado (CO) will be replaced because of its deteriorated condition. Our goal was to document the mold contamination and particulate matter (PM2.5) concentrations in Sun Valley homes and the circulatory and respiratory health of Sun Valley compared to all Denver residents (total 2761 and 1,049,046, respectively) based on insurance claims data for 2015 to 2019. Mold contamination in Sun Valley homes (n = 49) was quantified using the Environmental Relative Moldiness Index (ERMI) scale. Indoor PM2.5 concentrations were measured in Sun Valley homes (n = 11) using time-integrated, filter-based samples and quantified using gravimetric analysis. Outdoor PM2.5 concentrations data were obtained from a near-by United States Environmental Protection Agency monitoring station. In Sun Valley homes, the average ERMI value was 5.25 compared to -1.25 for other Denver homes. The PM2.5 median concentration inside Sun Valley homes was 7.6 μg/m3 (interquartile range - 6.4 μg/m3). The ratio of indoor to outdoor concentrations of PM2.5 was 2.3 (interquartile range - 1.5). In the last five years, ischemic heart disease was significantly more likely for Denver compared to Sun Valley residents. However, acute upper respiratory infections, chronic lower respiratory diseases and asthma were all significantly more likely for Sun Valley than Denver residents. Since the process of replacing and occupying the new housing will take several years, the next phase of the study will not occur until that process is complete.

Stroke: Molecular mechanisms and therapies: Update on recent developments

Stroke, a neurological disease, is one of the leading causes of death worldwide, resulting in long-term disability in most survivors. Annual stroke costs in the United States alone were estimated at $46 billion recently. Stroke pathophysiology is complex, involving multiple causal factors, among which atherosclerosis, thrombus, and embolus are prevalent. The molecular mechanisms involved in the pathophysiology are essential to understanding targeted drug development. Some common mechanisms are excitotoxicity and calcium overload, oxidative stress, and neuroinflammation. In addition, various modifiable and non-modifiable risk factors increase the chances of stroke manifolds. Once a patient encounters a stroke, complete restoration of motor ability and cognitive skills is often rare. Therefore, shaping therapeutic strategies is paramount for finding a viable therapeutic agent. Apart from tPA, an FDA-approved therapy that is applied in most stroke cases, many other therapeutic strategies have been met with limited success. Stroke therapies often involve a combination of multiple strategies to restore the patient's normal function. Certain drugs like Gamma-aminobutyric receptor agonists (GABA), Glutamate Receptor inhibitors, Sodium, and Calcium channel blockers, and fibrinogen-depleting agents have shown promise in stroke treatment. Recently, a drug, DM199, a recombinant (synthetic) form of a naturally occurring protein called human tissue kallikrein-1 (KLK1), has shown great potential in treating stroke with fewer side effects. Furthermore, DM199 has been found to overcome the limitations presented when using tPA and/or mechanical thrombectomy. Cell-based therapies like Neural Stem Cells, Hematopoietic stem cells (HSCs), and Human umbilical cord blood-derived mesenchymal stem cells (HUCB-MSCs) are also being explored as a treatment of choice for stroke. These therapeutic agents come with merits and demerits, but continuous research and efforts are being made to develop the best therapeutic strategies to minimize the damage post-stroke and restore complete neurological function in stroke patients.

Motor sequela of adult and pediatric stroke: Imminent losses and ultimate gains

Stroke is the leading cause of neurological disability in the United States and worldwide. Remarkable advances have been made over the past 20 years in acute vascular treatments to reduce infarct size and improve neurological outcome. Substantially less progress has been made in the understanding and clinical approaches to neurological recovery after stroke. This chapter reviews the epidemiology, bedside examination, localization approaches, and classification of stroke, with an emphasis on motor stroke presentations and management, and promising research approaches to enhancing motor aspects of stroke recovery.

SARS-CoV-2 Infection and Increased Risk for Pediatric Stroke

BACKGROUND

There is an increased risk of stroke in adults with severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 [COVID-19]) infection, but whether there is a similar association with stroke in children is unclear. Our objective was to determine whether there is a correlation between COVID-19 infection, multisystem inflammatory syndrome in children (MIS-C), and pediatric ischemic stroke.

METHODS

This was a retrospective, population-based cohort analysis between March 1, 2020, and June 30, 2021, conducted at a children's hospital. Pediatric patients with a diagnosis of ischemic stroke were identified using ICD-10 diagnoses of ischemic stroke, cerebrovascular accident, or cerebral infarction.

RESULTS

We identified 16 patients, seven male and nine female, with ischemic stroke. Ages were 8 months to 17 years (median 11.5 years). More Asian (6%) and black (13%) patients had strokes compared with population prevalence (2% each, respectively). No patients had active COVID-19 infection. COVID-19 antibodies were identified in five of 11 patients tested (45%), of whom three were diagnosed with MIS-C. 82% of the strokes occurred between February and May 2021. The peak incidence was in February 2021, which was two months after peak incidence of pediatric cases of COVID-19 and one month after the peak of MIS-C cases.

CONCLUSIONS

Our study suggests that prior COVID-19 infection, but not acute infection, is correlated with a risk for stroke in the pediatric population. The risk for stroke appears to be distinct from the risk for MIS-C.

Acute symptomatic seizures and hippocampal sclerosis: the major contributor for post-stroke epilepsy?

OBJECTIVE

Hippocampal sclerosis (HS) is a prominent biomarker of epilepsy. If acquired later in life, it usually occurs in the context of degenerative or acute inflammatory-infectious disease. Conversely, acute symptomatic seizures (ASS) are considered a risk factor for developing post-stroke epilepsy, but other factors remain unrecognized. Here, we hypothesize that silent hippocampal injury contributes to the development of post-stroke epilepsy.

METHODS

We performed a retrospective observational study of patients hospitalized between 1/2007 and 12/2018 with an acute stroke in the Stroke Center of the Geneva University Hospital. Patients were included if they had a documented normal hippocampal complex at onset and a control MRI at ≥ 2 year interval without new lesion in the meantime.

RESULTS

162 patients fulfilled our inclusion criteria. ASS during the first week (p < 0.0001) and epileptiform abnormalities in electroencephalography (EEG; p = 0.02) were more frequently associated with the development of epilepsy. Hemorrhagic stroke was strongly associated to both ASS and future focal epilepsy (p = 0.00097). Three patients (1.8%) developed hippocampal sclerosis ipsilateral to the cerebrovascular event between 2 and 5 years, all with ASS and hemorrhagic stroke.

INTERPRETATION

ASS and epileptiform EEG abnormalities are strong predictors of post-stroke epilepsy. HS develops in a minority of patients after hemorrhagic lesions, leading to focal epilepsy. Prospective studies are required, including follow-up with EEG and if characterized by epileptiform discharges, with MRI, to determine the true frequency of HS and to better understand predictors of post-stroke epilepsy (AAS, stroke type, and HS), and their impact on stroke recovery.

Targeting Nrf2 in ischemia-reperfusion alleviation: From signaling networks to therapeutic targeting

The nuclear factor erythroid 2-related factor 2 (Nrf2) is a master regulator of redox balance and it responds to various cell stresses that oxidative stress is the most well-known one. The Nrf2 should undergo nuclear translocation to exert its protective impacts and decrease ROS production. On the other hand, ischemic/reperfusion (I/R) injury is a pathological event resulting from low blood flow to an organ and followed by reperfusion. The I/R induces cell injury and organ dysfunction. The present review focuses on Nrf2 function in alleviation of I/R injury. Stimulating of Nrf2 signaling ameliorates I/R injury in various organs including lung, liver, brain, testis and heart. The Nrf2 enhances activity of antioxidant enzymes to reduce ROS production and prevent oxidative stress-mediated cell death. Besides, Nrf2 reduces inflammation via decreasing levels of pro-inflammatory factors including IL-6, IL-1β and TNF-α. Nrf2 signaling is beneficial in preventing apoptosis and increasing cell viability. Nrf2 induces autophagy to prevent apoptosis during I/R injury. Furthermore, it can interact with other molecular pathways including PI3K/Akt, NF-κB, miRNAs, lncRNAs and GSK-3β among others, to ameliorate I/R injury. The therapeutic agents, most of them are phytochemicals such as resveratrol, berberine and curcumin, induce Nrf2 signaling in I/R injury alleviation.

Development and validation of a composite score to predict severe forms of ischemic colitis

OBJECTIVE

To develop a simple scoring system in order to predict the risk of severe (death and/or surgery) ischemic colitis METHODS: In this retrospective study, 205 patients diagnosed with ischemic colitis in a tertiary hospital were consecutively included over a 6-year period. The study sample was sequentially divided into a training cohort (n = 103) and a validation cohort (n = 102). In the training cohort, multivariable analysis was used to identify clinical, biological, and CT variables associated with poor outcome and to build a risk scoring system. The discriminative ability of the score (sensitivity, specificity, positive predictive value, negative predictive value) was estimated in the two cohorts to externally validate the score, and a receiver operating characteristic curve was established to estimate the area under the curve of the score. Bootstrapping was used to validate the score internally.

RESULTS

In the training cohort, four independent variables were associated with unfavorable outcome: hemodynamic instability (2 pts), involvement of the small bowel (1 pt), paper-thin wall pattern (3 pts), no stratified enhancement pattern (1 pt). The score was used to categorize patients into low risk (score: 0, 1), high risk (score: 2-3), and very high risk (score: 4-7) groups with sensitivity and specificity of 97% and 67%, respectively, and a good discriminating capability, with a C-statistic of 0.94. Internal and external validation showed good discrimination capability (C-statistics of 0.9 and 0.84, respectively).

CONCLUSION

A simple risk score can stratify patients into three distinct prognosis groups, which can optimize patient management.

CLINICAL TRIAL NUMBER

NCT04662268 KEY POINTS: • Simple scoring system predicting the risk of severe ischemic colitis • First study to include CT findings to the clinical and biological data used to determine a severity score.

Sex differences in the association between diabetes and hypertension and the risk of stroke: cohort of the Tehran Lipid and Glucose Study

Background

We assessed the sex differences in the association between blood pressure categories and glucose intolerance status with overall and ischemic stroke among Iranian adults.

Methods

This prospective study was conducted on 5349 individuals (2446 men) aged ≥ 40 years. Cox models were used to estimate adjusted hazard ratios (HRs) and men-to-women ratios of HRs (RHRs) of overall and ischemic stroke for systolic (SBP) and diastolic (DBP) blood pressure, pre-hypertension, hypertension, fasting plasma glucose (FPG), pre-diabetes and type 2 diabetes (T2D).

Results

Each 0.55 mmol/L increase in FPG was associated with a higher HR of overall stroke in men than women [RHRs 1.05 (1.01–1.09)]. The associations between each 10 mmHg increase in DBP and stroke events were stronger in men than women, with RHRs of 1.20 (1.00–1.45) and 1.29 (1.04–1.60) for overall and ischemic stroke, respectively. Hypertension was associated with a higher HR of overall [RHRs: 2.41 (1.21–4.8)] and ischemic stroke [2.37 (1.12–5.01)] in men than women. We also found that T2D was associated with higher risks of overall and ischemic stroke in men than women: the RHRs were 2.16 (1.24–3.75) and 1.93 (1.05–3.55) for overall and ischemic stroke, respectively.

Conclusion

Hypertension and T2D induced higher risk of overall and ischemic stroke in men than women among Iranian population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13293-022-00421-7.

The associations between diastolic blood pressure and stroke events were stronger in men than women.

The fasting blood plasma level was associated with higher risk of stroke events in men than women.

Hypertension and diabetes were associated with higher risk of stroke events in men than women.

The association between systolic blood pressure with ischemic stroke was higher in men than women.

Outcomes of Mechanical Thrombectomy for Ischemic Stroke in Nonagenarians: A 10-Year Institutional Experience

BACKGROUND

Nonagenarians have been underrepresented in stroke trials that established endovascular treatment as the standard for acute ischemic stroke (AIS). Evidence remains inconclusive regarding the efficacy of thrombectomy in this population.

OBJECTIVES

To report our experience with thrombectomy in nonagenarians with stroke, and to identify predictors of mortality. We further investigated the effects of first-pass reperfusion and the addition of intravenous thrombolysis (IVT) on achieving better outcomes.

MATERIALS AND METHODS

Data was collected for consecutively treated patients at three affiliated comprehensive stroke centers from 2010 to 2021. We included patients ≥90 years-old with AIS secondary to large vessel occlusion. Bivariate analyses were performed using the Mann-Whitney U test for continuous variables, and χ² and Fisher's exact tests, respectively, for nominal and ordinal variables.

RESULTS

Thirty-two nonagenarians underwent thrombectomy, of whom 25 (81%) had prestroke mRS ≤2. Thrombectomies were performed using stents (2, 6.7%), aspiration (8, 26.7%), or a combination of both (20, 66.7%). Successful recanalization was achieved in 97%. Procedural complications occurred in 2 (6.3%) and intracranial hemorrhage in 3 (9.4%). Sixteen patients (50%) were discharged home or to rehabilitation, 9 (28.2%) to nursing home or hospice, and 7 (21.9%) died during hospitalization. Only 2 (6%) patients had mRS ≤2 at discharge. No independent predictors of in-hospital mortality were identified, and neither first-pass reperfusion nor the addition of IVT correlated with improvement in clinical outcome.

CONCLUSIONS

Although thrombectomy is safe for nonagenarian stroke and can achieve excellent recanalization, high mortality and poor functional status remain high given the advanced age and frailty of this population.

Healthcare Resource Utilization, Cardiovascular Event Rate and Use of Lipid-Lowering Therapies in Secondary Prevention of ASCVD in Hospitalized Patients in Italy

Introduction

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of mortality in Italy, accounting for 22% of total deaths. Lowering low-density lipoprotein cholesterol (LDL-C) levels reduces the risk of cardiovascular (CV) events; thus, lipid-lowering therapy (LLT) is the first-line treatment for patients with ASCVD and hypercholesterolaemia. However, many patients with ASCVD fail to reach LDL-C treatment thresholds, leaving them at greater risk of CV events. Inpatient care accounts for 51% of total expenditure on cardiovascular disease in the European Union, but healthcare resource utilization (HCRU) data for ASCVD in Italy is limited.

Methods

The study analysed healthcare claims data for 17,881 patients with acute coronary syndrome, ischemic stroke or peripheral artery disease from the Umbria 2 and Marche regions of Italy. LLT treatment patterns and CV event rates were collected and HCRU estimated in the year before and after the index event.

Results

High-intensity LLTs were prescribed to 44.3% of patients and 49.6% received moderate-/low-intensity LLTs during the 6 months after the index event. The first year CV event rate was 18.0/100 patient-years for patients receiving high-intensity LLTs and 17.2/100 patient-years for those on moderate-/low-intensity LLTs. Higher costs were associated with patients untreated with LLT 6 months post-index event (€8323) than patients prescribed high-intensity (€6278) or moderate-/low-intensity LLTs (€6270). Hospitalization accounted for most of the total costs.

Conclusions

This study found that CV events in secondary prevention Italian patients are associated with substantial HCRU and costs. More intensive LDL-C lowering can prevent CV events, easing the financial burden on the healthcare system.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-01960-y.

Long-term mortality in patients with moyamoya angiopathy according to stroke presentation type in South Korea

BACKGROUND

Incidence, prevalence, and long-term survival outcomes in patients with moyamoya angiopathy (MMA) according to stroke presentation type and age group have not been clearly elucidated.

METHODS

We investigated mortality in patients with MMA (moyamoya disease, probable moyamoya disease, moyamoya syndrome) of whose International Classification Disease 10 code was I67.5 from 2006 to 2015 using the Korean National Health Insurance database. MMA at diagnosis was classified into 3 types (ischemic, hemorrhagic, and asymptomatic or else) according to stroke presentation. Survival analysis was performed according to stroke presentation type and age group (< 15 years and ≥ 15 years) using the Kaplan-Meier method.

RESULTS

There were 12,146 newly diagnosed moyamoya cases, with a female-to-male ratio of 1.81; the ischemic type was identified in 3671 (30.2%) patients, the hemorrhagic type in 2449 (20.2%) patients, and the asymptomatic or else type in 6026 (49.6%) patients. The mean age at diagnosis according to stroke presentation was 33.1 (± 14.8) years in asymptomatic or else type, 41.2 (± 17.3) years in ischemic type, and 45.4 (± 14.3) years in hemorrhagic type (P < 0.001). The 10-year survival rates in ischemic-, hemorrhagic-, and asymptomatic or else-type patients were 88.9%, 76.3%, and 94.3%, respectively (log-rank test; P < 0.001). Pediatric MMA (< 15 years) and adult MMA (≥ 15 years) showed different survival curves according to stroke presentation type (log-rank test; P = 0.017, P < 0.001, respectively).

CONCLUSIONS

Our study showed that moyamoya patients had different diagnosis ages and distinct survival courses according to stroke presentation type. Adult moyamoya patients with hemorrhagic presentation had the worst survival outcomes.

Long-term exposure to road traffic noise and stroke incidence: a Danish Nurse Cohort study

BACKGROUND

Road traffic noise has been linked to increased risk of ischemic heart disease, yet evidence on stroke shows mixed results. We examine the association between long-term exposure to road traffic noise and incidence of stroke, overall and by subtype (ischemic or hemorrhagic), after adjustment for air pollution.

METHODS

Twenty-five thousand six hundred and sixty female nurses from the Danish Nurse Cohort recruited in 1993 or 1999 were followed for stroke-related first-ever hospital contact until December 31st, 2014. Full residential address histories since 1970 were obtained and annual means of road traffic noise (L_den [dB]) and air pollutants (particulate matter with diameter < 2.5 μm and < 10 μm [PM_2.5 and PM₁₀], nitrogen dioxide [NO₂], nitrogen oxides [NOx]) were determined using validated models. Time-varying Cox regression models were used to estimate hazard ratios (HR) (95% confidence intervals [CI]) for the associations of one-, three-, and 23-year running means of L_den preceding stroke (all, ischemic or hemorrhagic), adjusting for stroke risk factors and air pollutants. The World Health Organization and the Danish government's maximum exposure recommendations of 53 and 58 dB, respectively, were explored as potential L_den thresholds.

RESULTS

Of 25,660 nurses, 1237 developed their first stroke (1089 ischemic, 148 hemorrhagic) during 16 years mean follow-up. For associations between a 1-year mean of L_den and overall stroke incidence, the estimated HR (95% CI) in the fully adjusted model was 1.06 (0.98-1.14) per 10 dB, which attenuated to 1.01 (0.93-1.09) and 1.00 (0.91-1.09) in models further adjusted for PM_2.5 or NO₂, respectively. Associations for other exposure periods or separately for ischemic or hemorrhagic stroke were similar. There was no evidence of a threshold association between L_den and stroke.

CONCLUSIONS

Long-term exposure to road traffic noise was suggestively positively associated with the risk of overall stroke, although not after adjusting for air pollution.

Neuroprotective Role of Acidosis in Ischemia: Review of the Preclinical Evidence

Efforts to develop effective neuroprotective therapies for ischemic stroke have had little success to date. One promising approach to neuroprotection is ischemic postconditioning, which utilizes brief bouts of ischemia after acute ischemic stroke to elicit neuroprotection, although the mechanism is largely unknown. As the primary components of transient ischemia are local hypoxia and acidosis, and hypoxic postconditioning has had little success, it is possible that the acidosis component may be the primary driver. To address the evidence behind this, we performed a systematic review of preclinical studies focused on the neuroprotective role of transient acidosis after ischemia. Animal studies demonstrated that mild-to-moderate acidosis after ischemic events led to better functional neurologic outcomes with reduced infarct volumes, while severe acidosis often led to cerebral edema and worse functional outcomes. In vitro studies demonstrated that mild-to-moderate acidosis improves neuronal survival largely through two means: (1) inhibition of harmful superoxide formation in the excitotoxic pathway and (2) remodeling neuronal mitochondria to allow for efficient ATP production (i.e., oxidative phosphorylation), even in the absence of oxygen. Similar to the animal studies, acidotic postconditioning in humans would entail short cycles of carbon dioxide inhalation, which has already been demonstrated to be safe as part of a hypercapnic challenge when measuring cerebrovascular reactivity. Due to the preclinical efficacy of acidotic postconditioning, its relatively straightforward translation into humans, and the growing need for neuroprotective therapies, future preclinical studies should focus on filling the current knowledge gaps that are currently restricting the development of phase I/II clinical trials.

Nucleoporin 50 mediates Kcna4 transcription to regulate cardiac electrical activity

Emerging evidence has demonstrated that nucleoporins (Nups) play a pivotal role in cell-type-specific gene regulation, but how they control the expression and activity of ion channel genes in the heart remains unclear. Here, we show that Nup50, which is localized in the nucleus of cardiomyocytes, selectively induces an increase in the transcription and translation of Kcna4. The Kcna4 gene encodes a K+ voltage-gated channel of shaker-related subfamily member 4 and is essential for regulating the action potential in cardiac membranes. Using immunofluorescence imaging, luciferase assays and chromatin immunoprecipitation assays, we identified that the direct binding of the FG-repeat domain within Nup50 to the proximity of the Kcna4 promoter was required to activate the transcription and subsequent translation of Kcna4. Functionally, Nup50 overexpression increased the currents of KCNA4-encoded Ito,s channels, and reverse knockdown of Nup50 resulted in a remarkable decrease in the amplitude of Ito,s currents in cardiomyocytes. Moreover, a positive correlation between Nup50 and Kcna4 mRNA and protein expression was observed in heart tissues subjected to ischemic insults. These findings provide insights into the homeostatic control of cardiac electrophysiology through Nup-mediated regulation.

Timing of Anticoagulation after Stroke in Patients with Non-Valvular Atrial Fibrillation Assessment of Provider Practices

BACKGROUND

Optimal timing of oral anticoagulation (TOAC) in acute ischemic stroke (AIS) in patients with atrial fibrillation (AF) is unknown. The risk of recurrent ischemic events when treatment is delayed is often weighed against that of hemorrhagic transformation (HT) when anticoagulation is started in the subacute phase, especially in moderate to large infarctions. Despite substantial evidence for the benefit of oral anticoagulation (OAC) in reducing stroke recurrence, current nationally recognized practice guidelines do not provide clear recommendations on the TOAC after AF-related AIS.

MATERIALS AND METHODS

We surveyed neurologists on therapeutic approaches to timing of anticoagulation after stroke in patients with AF (without moderate or severe mitral stenosis or a mechanical heart valve) using an online questionnaire. Several ischemic and hemorrhagic stroke scenarios with various stroke sizes, locations, and high-risk thrombotic complications were presented, and survey respondents were asked to provide post-stroke timeframe for TOAC. Practice background, specialty and years of experience of respondents were recorded.

RESULTS

Majority of participants favored early initiation of OAC in small infarcts. In moderate to larger infarct burden, or when ischemia was complicated by HT, there was an overall trend to delay any initiation of OAC, irrespective of specialty or years of experience. The overt presence of an additional cardiac embolic source such as cardiac thrombus led decisions for early anticoagulation.

CONCLUSION

Although general practice trends were captured, optimal TOAC following AIS in AF remains unknown. Further research is warranted to determine optimal timing and anticoagulant selection.

Vγ4 T cell-derived IL-17A is essential for amplification of inflammatory cascades in ischemic brain tissue after stroke

BACKGROUND

Through amplifying inflammatory cascades, IL-17A produced by γδ T cells potently attracts neutrophils to the site of injury for exacerbating ischemic tissue damage. Our goal was to identify the precise role of γδ T cell subsets in ischemic brain tissue damage of stroke.

METHODS

In a model of experimental stroke, we analyzed the functions of Vγ1 and Vγ4 T cells on γδ T cell-mediated ischemic brain tissue damage of stroke.

RESULTS

We identified that, in stroke, Vγ4 T cells are essential for γδ T cell-mediated ischemic brain tissue damage through providing an early source of IL-17A. Both CCL20 and IL-1β/IL-23 are deeply involved in Vγ4 T cell-mediated amplification of inflammatory responses: CCL20 might promote Vγ4 T cells recruit to infract hemisphere, and IL-1β/IL-23 powerfully enhance IL-17A production mediated by the infiltrating Vγ4 T cells. Moreover, Vγ4 T cell-derived IL-17A enhances both CCL20 and IL-1β, and conversely, CCL20 and IL-1β further enhance both recruitment and IL-17A production of IL-17A-positive cells, in a classic positive feedback loop.

CONCLUSION

Our data suggest that in the setting of ischemic stroke, Vγ4 T cell-derived IL-17A, CCL20 and IL-1β/IL-23 in infract hemisphere coordinately to amplify inflammatory cascades and exacerbate ischemic tissue damage.

Endovascular treatment of symptomatic intracranial atherosclerotic stenosis with low profile visualized intraluminal support stent

OBJECTIVE

Severe intracranial atherosclerotic stenosis has become one of the main causes resulting transient ischemic attack and stroke. This study aimed to evaluate the efficacy and safety of low profile visualized intraluminal support (LVIS) stent in treating symptomatic intracranial atherosclerotic stenosis.

METHODS

Data of 31 patients with at least 70% stenosis treated with LVIS stent in our center were retrospectively collected between July 2017 and November 2020. Further evaluation of lesion characteristics, technical success rate, preoperative complication, clinical and angiographic follow-up outcome, delayed in-stent stenosis were conducted.

RESULTS

Stent delivery and deployment were successfully achieved in all 31 patients (100%). 22 cases (71%) were located in anterior circulation and 9 cases (29%) were located in posterior circulation. The mean degree of stenosis lesion before stent deployment was 85.6 ± 9.4%, while after stenting was 11.2 ± 11.8%. One patient suffered from ischemic complication in stenting procedure, and timely delivery of rt-PA successfully recanalized the artery. Clinical follow-up was available in all 31patients (100%) with mean follow-up time 15.0 ± 12.1(3-45) months. No patients experienced the recurrence of stroke or TIA or death after discharge. Angiographic follow-up was available in 21patients (67.7%) with mean follow-up time 11.43 ± 6.8 (6-36) months. 19 patients (90.5%) were stable while 2 patients (9.5%) developed ISR in their last angiographic follow-up. The 2 patients received balloon angioplasty and reached satisfactory results after retreatment.

CONCLUSION

This preliminary study suggests that LVIS stent deployment was a feasible approach in treating intracranial atherosclerotic stenosis with satisfactory procedure success rate, low complication rate and favorable long-term outcome.

Heparin for Vertebral Intraluminal Thrombus Causing Retroperitoneal Hemorrhage from Occult Renal Angiomyolipoma

Stroke is a common cause of mortality and serious long-term disability worldwide. In the acute setting, current American Heart Association/American Stroke Association guidelines do not recommend routine anticoagulation for the management of acute ischemic strokes. However, short-term use of unfractionated heparin (UFH) in select subpopulations has demonstrated improved outcomes. While tools such as CHADSVASC and HASBLED scores are useful in stratifying risk of long-term anticoagulation in patients with nonvalvular atrial fibrillation and additional risk factors, the carefully selected patient populations for the design of these studies do not account for risk of hemorrhage from other preexisting conditions. Here, we present a patient with a posterior circulation intraluminal thrombus treated with UFH, who manifested with a near-fatal intra-abdominal hemorrhage from a previously undetected renal angiomyolipoma (AML).

Ischemic volvulus of the transverse colon caused by intestinal malrotation: A case report

Introduction

Congenital Intestinal malrotation is a complex disorder caused by incomplete or abnormal rotation of the intestine during fetal development. Volvulus of the transverse colon secondary to intestinal malrotation is a rare cause of acute abdomen in adults. It has a high risk of mortality, hence the need for an urgent diagnosis and surgical intervention.

Case report

We report an unusual case of volvulus of the transverse colon caused by intestinal malrotation. A 21-year-old women presented abdominal pain with nausea and vomiting. On clinical examination, the abdomen was tympanic to percussion with peritoneal sensitivity. The abdominal X-ray revealed a massive obstruction of the distended large intestine with a “U-shaped” loop. He underwent an exploratory laparotomy that revealed the diagnosis of transverse colon volvulus with intestinal malrotation. His condition was treated surgically by transverse colectomy with colostomy. The patient died on the second day following a hemodynamic instability.

Conclusion

Transverse colonic volvulus is a rare entity with a high mortality, so it requires urgent diagnosis and surgical intervention.

•

Volvulus of the transverse colon secondary to intestinal malrotation is a rare cause of an acute abdomen in adults.

•

Volvulus of the transverse colon has a high risk of mortality, so it requires urgent diagnosis and surgical intervention.

•

The diagnosis of the volvulus of the transverse colon before surgery is rarely observed, it's most often made intraoperatively.

•

The choice of a procedure depends on the general condition of the patient.

The importance of previous lifetime trauma in stroke-induced PTSD symptoms and mental health outcomes

The 'Stroke Complications after Traumatic Experiences and Stress' (SATURN) study was designed to investigate the effects of a prior traumatic event on PTSD symptoms triggered by a subsequent stroke. First-ever ischemic stroke patients were surveyed 9-13 months after hospitalization at the Charité University Medical Center. Stroke-induced PTSD symptoms were measured using the Impact of Event Scale-revised (IES-R). Prior traumatization together with past PTSD symptoms was assessed retrospectively with the Brief Trauma Questionnaire (BTQ) and the 7-item Short Screening Scale for PTSD. Depressive symptoms were assessed with the Beck Depression Inventory (BDI-II). The Short Form (SF)-36 was used to evaluate physical and mental health outcomes. We received 258 responses from 636 eligible patients (~41%). Based on respondents' scores on the IES-R, the prevalence of probable PTSD due to the stroke event was 11% in our sample. Female sex and younger age were associated with more severe PTSD symptoms. Psychological endpoints did not differ between patients who denied prior trauma exposure and those who reported earlier trauma exposure but denied subsequent PTSD symptoms. However, a history of trauma exposure in tandem with endorsing subsequent PTSD symptoms was linked with significantly increased post-stroke PTSD and depressive symptoms together with decreased psychological well-being. Self-reported physical health did not differ across groups. Younger age, being a woman, and having developed PTSD symptoms in the aftermath of a prior trauma were associated with adverse psychological outcomes after stroke.

Hypertension and childhood stroke

Cerebrovascular disease (stroke) is one of the ten leading causes of death in children and adolescents. Multiple etiologies, from arteriopathies to prothrombic states, can cause stroke in youth. In adult stroke, hypertension has been shown to be the single most important modifiable risk factor. Although hypertension has not been strongly identified as a risk factor in childhood stroke to date, there is preliminary evidence that suggests that hypertension may also be associated with stroke in children. In this review, we summarize the literature that may link hypertension to stroke in the young. We have identified a series of barriers and limitations in the fields of pediatric hypertension and pediatric neurology that might explain why hypertension has been overlooked in childhood stroke. We suggest that hypertension may be a relevant risk factor that, alone or in combination with other multiple factors, contributes to the development of stroke in children. Currently, there are no consensus guidelines for the management of post-stroke hypertension in children. Thus, we recommend that blood pressure be assessed carefully in every child presenting with acute stroke in order to better understand the effects of hypertension in the development and the outcome of childhood stroke. We suggest a treatment algorithm to help practitioners manage hypertension after a stroke.

Apolipoprotein E genotype does not influence the risk of symptomatic hemorrhage in acute ischemic stroke

BACKGROUND

APOE ε4 is independently associated with lobar intracranial hemorrhages (ICH). Although the ε4 allele enhances amyloid deposition in blood vessels, the ε2 allele predisposes to vasculopathic changes leading to rupture of amyloid laden vessels. Thus, ε4 and ε2 carriers might have increased susceptibility to ICH. We aimed to study the impact of the apolipoprotein E alleles in the development of symptomatic ICH (sICH).

METHODS

We included 384 consecutive ischemic anterior circulation stroke patients submitted to thrombolysis between January 2014 and March 2016. Admission CT-scans were reviewed to calculate the ASPECTS. Patients were followed for up to at least 6 months post-stroke or until death. Outcome was development of sICH, defined according to the ECASS III.

RESULTS

Considering APOE genotyping, three patients had ε2/ε2, four had ε2/ε4, 38 had ε2/ε3, 284 had ε3/ε3, 51 had ε3/ε4 and four had ε4/ε4. sICH was associated with sex and diabetes. In multivariate analysis, sICH was not associated with carrying one or more ε4 alleles (OR: 0.483, 95%CI = [0.059, 3.939], p = 0.497) nor with carrying one or more ε2 alleles (OR: 1.369, 95%CI = [0.278, 6.734], p = 0.699).

CONCLUSION

No association was found between APOE genotype and the development of symptomatic intracranial hemorrhage.

Trends in endovascular interventions for pediatric ischemic stroke at the national level: data from 2000 to 2009

PURPOSE

Present knowledge is limited with regard to endovascular and interventional management of pediatric acute ischemic stroke (AIS). The current practice of neurointerventions in this population was analyzed via a national database.

METHODS

The Kids' Inpatient Database for years 2000, 2003, 2006, and 2009 was examined for patients aged < 18 years discharged with a primary diagnosis of AIS and identified according to ICD-9 codes. Descriptive statistics were tabulated on each of the subcohorts.

RESULTS

There were 3467 patients identified; 920 (26.5%) underwent angiograms, 51 (1.5%) angiogram + thrombolysis, and 18 (0.5%) received angiogram + endovascular recanalization. The angiogram only subcohort was significantly younger compared with thrombolysis and endovascular procedure subcohorts (9.8 vs. 12.2 vs. 14.9 years, P < 0.001). Mortality was 4.3%, significantly lower for angiogram only than for thrombolysis (1.1% vs. 18.2%, P < 0.0001). Thrombolysis also had significantly higher hospital charges ($149,045 vs. $64,826, P < 0.0001). While not many differences in outcomes between angiogram only versus endovascular procedures, the latter had higher financial burden ($122,482 vs. $64,826, P < 0.0001).

CONCLUSIONS

This national study suggests that children receiving neurointerventions tend to be older (> 12 years) and heart and valvular defects are their most likely comorbidities. There was a lower mortality and fewer complications with endovascular procedures when compared with intravenous/intraarterial thrombolysis alone. Thrombolysis was also associated with more non-routine discharges and lengthier stay.

Clinical characteristics and admission patterns of stroke patients during the COVID 19 pandemic: A single center retrospective, observational study from the Abu Dhabi, United Arab Emirates

OBJECTIVE

To compare ischemic and hemorrhagic stroke patients with COVID-19 to non-COVID-19 controls, and to describe changes in stroke admission patterns during the pandemic.

METHODS

This is a single center, retrospective, observational study. All consecutive patients admitted with primary diagnosis of ischemic/ hemorrhagic stroke between March1st -May10th 2020 were included and compared with the same time period in 2019.

RESULTS

There was a 41.9% increase in stroke admissions in 2020 (148 vs 210,P = .001). When comparing all ischemic strokes, higher rate of large vessel occlusion (LVO) (18.3% vs 33.8%,P = .008) and significant delay in initiation of mechanical thrombectomy after hospital arrival (67.75 vs 104.30 minutes,P = .001) was observed in 2020. When comparing all hemorrhagic strokes, there were no differences between the two years. Among 591 COVID-19 admissions, 31 (5.24%) patients with stroke including 19 with ischemic (3.21%) and 12 with hemorrhagic stroke (2.03%) were identified. Patients with COVID-19 and ischemic stroke were significantly younger (58.74 vs 48.11 years,P = .002), predominantly male (68.18% vs 94.74%,P = .016), had lesser vascular risk factors, had more severe clinical presentation (NIHSS 7.01 vs 17.05,P < .001), and higher rate of LVO (23.6% vs. 63.1%,P = .006). There was no difference in the rate of endovascular thrombectomy, but time to groin puncture was significantly longer in COVID-19 patients (83.41 vs 129.50 minutes,P = .003). For hemorrhagic stroke, COVID-19 patients did not differ from non-COVID-19 patients.

CONCLUSIONS

Stroke continues to occur during this pandemic and stroke pathways have been affected by the pandemic. Stroke occurs in approximately 5% of patients with COVID-19. COVID-19 associated ischemic stroke occurs in predominantly male patients who are younger, with fewer vascular risk factors, can be more severe, and have higher rates of LVO. Despite an increase in LVO during the pandemic, treatment with mechanical thrombectomy has not increased. COVID-19 associated hemorrhagic stroke does not differ from non-COVID-19 hemorrhagic stroke patients.

A Rare Case of Capgras Syndrome in Moyamoya Disease

Moyamoya disease is a rare cerebrovascular disorder with unknown etiology and psychiatric symptoms occasionally manifest initially. Capgras syndrome is a unique neuropsychiatric symptom that is a delusional misidentification of a familiar person replaced by an identical imposter. We report the case of a 51-year-old woman with frontal lobe ischemic stroke caused by moyamoya disease, presenting with Capgras syndrome. Dysfunction of frontal areas may be attributable to development of Capgras syndrome.

Nasal Tip Deformities After Primary Rhinoplasty

Nasal tip deformities after primary rhinoplasty may occur, including the formation of bossae, a pinched nasal tip, and nasal tip ischemia. Because of the central location in the midface, even minimal nasal tip deformities (small bossa) may be noticed and upsetting to the patient. This is in addition to more severe nasal tip deformities, including nasal tip ischemia, that are easily visible to any viewer. Prevention, early recognition, and, depending on the case, intervention are critical in minimizing these complications. If complications do occur, regular communication with the patient and follow-up are crucial.

Predicting response of ischemic central retinal vein occlusion to bevacizumab injections: 1 year follow-up

PURPOSE

To identify baseline optical coherence tomography (OCT) factors in ischemic central retinal vein occlusion (CRVO) that predict response to bevacizumab injections.

METHODS

Patients underwent OCT at diagnosis and the central macular thickness, subretinal fluid width and height as well as the presence of intraretinal cysts were measured. The extent of disorganized retinal inner layers, outer plexiform layer (OPL), external limiting membrane, ellipsoid zone and cone outer segment tips (COST) was recorded. Patients received three consecutive monthly injections of bevacizumab followed by pro re nata treatment.

RESULTS

Overall 32 eyes of 32 patients aging 69.4 ± 12.7 years were included. In univariate correlational analyses baseline OPL disruption (- 41, p = 0.02), EZ disruption (r = - 0.36, p = 0.05) and COST disruption (r = - 0.37, p = 0.04) correlated with deterioration in BCVA at 1 year. Partial least squares demonstrated that the factors most largely associated with deterioration in BCVA were COST disruption and OPL disruption followed by EZ disruption, while worst vision at baseline was associated with improvement in vision.

CONCLUSION

In patients with ischemic CRVO treated with bevacizumab, BCVA improvement at 1 year can be partially predicted from baseline OCT measurements by the extent of COST, OPL and EZ disruption.

Using cyproterone acetate to treat recurrent ischemic priapism in a patient with sickle cell anemia as a comorbidity: a case report

Introduction

The management of recurrent ischemic priapism is unclear in contemporary practice. Yet, if left untreated, the condition may evolve into an acute ischemic priapism and in some cases result in erectile dysfunction. This report documents the results of successful management of recurrent ischemic priapism using cyproterone acetate in a 30-year-old Saudi man with sickle cell anemia as a comorbidity.

Case presentation

A 30-year-old Saudi man denoted visited the emergency room with a painful erection which had lasted for more than four hours. The patient has sickle cell anemia and a family history of sickle cell disease. He is married and has two children. His first priapism case occurred when he was 7 years old. At the age of 15, the condition recurred, and the patient’s doctor prescribed cyproterone acetate 50 mg twice daily for 5 days. The doctor had told him that whenever he was experiencing priapism, he should adhere to this regimen for 5 days. The doctor could not find any guidelines for the prescription of cyproterone acetate.

Conclusion

Priapism cases represent a significant challenge in therapeutic management because of the elevated risk of structural damage to the penis. The fact that there lacks a clinically approved standard approach to managing the condition make it difficult for physicians to effectively manage the condition. Management of the condition is further complicated by existence of comorbidities such as sickle cell anemia. This patient’s case demonstrates that cyproterone acetate prescription is a great preventative strategy that limits priapism recurrences.

Acute Ischemic and Hemorrhagic Stroke and COVID-19: Case Series

The coronavirus COVID-19 pandemic is the defining global health crisis of our time and the greatest challenge we have faced since the World Wars; it can attack several systems in the body and has high complications and mortality. COVID-19 can cause venous and arterial thromboembolism due to immobility, high inflammation, extensive intravascular blood coagulation, and hypoxia. In this study, we report 5 cases of adults with COVID-19, hospitalized in Tohid Hospital, Sanandaj, Iran. Three patients were male and two were female. The youngest patient was 20 years old and the oldest was 55 years old. All patients had at least one family member with coronavirus. Fever, chills, muscular pain, cough, and tachypnea were present in all patients. Red blood cell (RBC) was observed in all patients at a low level. Computed tomography (CT) scans of all patients showed abnormal findings in different areas of the brain. These cases indicate that COVID-19 may damage blood vessels in the brain and lead to stroke.

Exosomal shuttled miR-424-5p from ischemic preconditioned microglia mediates cerebral endothelial cell injury through negatively regulation of FGF2/STAT3 pathway

Exosomes secreted by microglia have been found to play a role in neurovascular unit injury under the ischemic/hypoxic state. However, the modulatory effect of exosomes shuttled miRNAs produced by microglia in endothelial cells remains undefined. Here, an oxygen-glucose deprivation (OGD) model was constructed both in microglia and brain microvascular endothelial cells (BMEC). The exosomes secreted by microglia were isolated, and the exosomal miRNA profile was detected. Next, gain- and loss- functions of miR-424-5p, one of the most differentially expressed miRNAs in microglia derived exosomes, were conducted in BMEC. The results demonstrated that exosomes from OGD-activated microglia aggravated OGD induced BMEC viability and integrity damage as well as the loss of vascular formation. While the damaging effects were markedly attenuated by inhibiting miR-424-5p. In addition, miR-424-5p overexpression significantly aggravated OGD induced BMEC damage and permeability. Mechanistically, bioinformatics analysis indicated that miR-424-5p targeted the FGF2 mediated STAT3 signaling pathway, which was verified via dual luciferase activity assay and RIP experiment. Furthermore, in vivo experiments in the middle cerebral artery occlusion (MCAO) model mice were conducted. The results revealed that inhibition of miR-424-5p markedly reduced neurological dysfunctions and endothelial cell injury induced by MCAO. The above results confirmed that exosomes from OGD activated microglia induced significant cell damage and permeability of BMEC, in which the upregulated miR-424-5p in the exosomes functioned by regulating FGF2/STAT3 pathway.

Electrocardiographic left atrial abnormality in patients presenting with ischemic stroke

BACKGROUND

P wave indices represent electrocardiographic marker of left atrial pathology. We hypothesized that P wave would be more abnormal in patients presenting with ischemic stroke than a comparable group without ischemic stroke.

METHODS

We compared P wave terminal force in V1 (PTFV1) between patients admitted with ischemic stroke (case) and patients followed in cardiology clinic (control) at a single medical center. Using logistic regression models, we tested for an association between abnormal PTFV1 (> 4000 µV ms) and ischemic stroke. We also defined several optimal cut-off values of PTFV1 using a LOESS plot and estimated odds ratio of ischemic stroke when moving from one cut-point level to the next higher-level.

RESULTS

A total of 297 patients (case 147, control 150) were included. PTFV1 was higher in patients with vs. those without ischemic stroke (median 4620 vs 3994 µV ms; p=0.006). PTFV1 was similar between cardioembolic/cryptogenic and other stroke subtypes. In multivariable analyses adjusting for sex, obesity, age, and hypertension, the association between abnormal PTFV1 and ischemic stroke ceased to be significant (OR 1.53 [0.95, 2.50], p=0.083). Increase to the next cutoff level of PTFV1 (900, 2000, 3000, 4000, 5000, and 6000 µV ms) was associated with 18% increase in odds of having ischemic stroke (vs. no ischemic stroke) (OR 1.18 [1.02, 1.36], p=0.026).

CONCLUSION

Patients presenting with acute ischemic stroke are more likely to have abnormal PTFV1. These findings from a real-world clinical setting support the results of cohort studies that left atrial pathology manifested as abnormal PTFV1 is associated with ischemic stroke.

Efficacy and Safety of Prasugrel by Stroke Subtype: A Sub-Analysis of the PRASTRO-I Randomized Controlled Trial

Aims: The efficacy of antiplatelet therapy may vary among different disease subtypes. Prasugrel is generally a more potent, consistent, and fast-acting platelet inhibitor than clopidogrel. This sub-analysis of the phase III comparison of PRAsugrel and clopidogrel in Japanese patients with ischemic STROke (PRASTRO-I) trial aimed to assess the differences in efficacy of these treatments for each stroke subtype.

Methods: In the PRASTRO-I trial, a total of 3,753 patients with ischemic stroke were recruited from 224 centers throughout Japan and randomized (1:1) to prasugrel (3.75 mg/day) or clopidogrel (75 mg/day) for 96 weeks. For the sub-analysis, strokes were classified as large-artery atherosclerosis, small-artery occlusion (lacunar), stroke of other etiology, and stroke of undetermined etiology. The cumulative incidence of primary events (ischemic stroke, myocardial infarction, and death from other vascular cause) and hazard ratios (HRs) were calculated for each subgroup.

Results: For patients with large-artery atherosclerosis, the primary event incidence was 3.8% in the prasugrel group and 4.8% in the clopidogrel group (HR 0.79; 95% confidence interval [CI] 0.45–1.41). For patients with small-artery occlusion, the incidence was 3.3% in the prasugrel group and 3.9% in the clopidogrel group (HR 0.82; 95% CI 0.45–1.50). For patients with stroke of undetermined etiology, the incidence was 4.6% in the prasugrel group and 3.0% in the clopidogrel group (HR 1.56; 95% CI 0.90–2.72). The incidence of bleeding was similar across subtypes.

Conclusions: Although statistical significance was not reached, the efficacy of prasugrel was potentially different between stroke subtypes, warranting further studies.

Cocaine- and amphetamine-regulated transcript protects synaptic structures in neurons after ischemic cerebral injury

Cocaine-regulated and amphetamine-regulated transcript (CART) is a neuropeptide with reported neuroprotective effects in ischemic cerebral injury. However, its mechanism has not yet been elucidated. Herein, we investigated the role and mechanism of CART in synaptic plasticity in neurons after ischemic cerebral stroke. We found that the survival rate of the oxygen-glucose deprivation (OGD) neurons was increased after CART treatment. Moreover, CART treatment significantly attenuated ischemia-induced neuronal synaptic damage and increased synaptophysin expression. In addition, the number of presynaptic vesicles was increased and the postsynaptic density (PSD) was thickened after CART treatment. Mechanistically, CART treatment enhanced the expression of Arc mRNA in a cAMP response element binding protein (CREB) dependent manner in OGD neurons, and blockade of CREB by KG-501 eliminated the protective effect of CART. Collectively, CART protected the synaptic structure in neurons after ischemic cerebral injury by increasing the Arc expression via upregulating p-CREB.

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.