Outcomes of recurrent stroke in patients with atrial fibrillation according to presumed etiology / Desfecho de AVC recorrente em pacientes com fibrilação atrial de acordo com etiologia presumida

Abstract Background Atrial fibrillation (AF) is a potent risk factor for stroke. The presence of competing etiologies can modify disease outcomes and demand different treatment strategies. Objective The primary purpose of the study was to examine the differences in outcomes for patients with AF admitted with a recurrent stroke, stratified according to the presumed etiology of the stroke. Methods We analyzed AF patients admitted for a recurrent ischemic stroke in an academic comprehensive stroke center. Recurrent strokes were categorized as "Cardioembolic", meaning AF without any competing mechanism, versus "Undetermined" etiology due to competing mechanisms. We used logistic regression to test the association between recurrent stroke etiology and favorable outcome (discharge home), after accounting for important covariates. Results We included 230 patients, with a mean age 76.9 (SD ± 11.3), 52.2% male, median National Institute of Health Stroke Scale (NIHSS) score of 7 (IQR 2-16). Patients with cardioembolic stroke (65.2%) had higher median NIHSS 8.5 (3-18) versus 3 (1-8) and were more likely to be treated with reperfusion therapies. The favorable outcome was reached by 64 patients (27.8%), and in-hospital mortality was 15.2% overall. After adjustment, there was no difference in outcome between patients with cardioembolic versus undetermined stroke etiology (odds ratio for discharge home: 1.41; 95% CI: 0.65-3.15). Conclusions In this single-center sample of AF patients with history of stroke, there was no difference in discharge outcomes between those with cardioembolic and those with undetermined stroke etiology. This question warrants examination in larger samples to better understand the importance of the stroke mechanism and secondary prophylaxis.

Resumo Antecedentes Fibrilação atrial (FA) é um fator de risco importante para AVC. A presença de mecanismos concorrentes para o AVC pode modificar o desfecho e demandar estratégias de tratamento diferentes. Objetivo O objetivo primário do estudo foi examinar diferenças no desfecho de pacientes com FA admitidos por um AVC recorrente, sendo estratificados de acordo com a etiologia presumida do AVC. Métodos Nós analisamos pacientes com FA admitidos por conta de AVC recorrente em um centro acadêmico terciário de AVC. Os casos de AVC recorrentes foram classificados como "Cardioembólicos", sendo FA sem outros mecanismos alternativos, versus aqueles de etiologia "Indeterminada" por conta de mecanismos concorrentes. Foi usada regressão logística para testar a associação entre a etiologia do AVC recorrente e desfecho favorável (alta direto para casa) após controle para covariáveis importantes. Resultados Nós incluímos 230 pacientes, com uma idade média 76,9 anos (DP ± 11.3), 52.2% homens, com um escore mediano do National Institute of Health Stroke Scale (NIHSS) de 7 (IIQ 2-16). Pacientes com AVC cardioembólicos (65,2%) tiveram um escore de NIHSS mediano mais alto 8,5 (3-18) versus 3 (1-8), e com maior chance de tratamento com terapias de reperfusão. O desfecho favorável ocorreu em 64 pacientes (27,8%) e a mortalidade institucional foi de 15,2% no total. Após ajustes, não encontramos diferença no desfecho entre pacientes com AVC cardioembólico versus AVC de etiologia indeterminada (odds ratio para alta para casa: 1,41; 95% IC: 0,65-3,15). Conclusões Nessa amostra de pacientes com FA e história de AVC recorrente de centro único, não houve diferença no desfecho de alta entre aqueles com AVC cardioembólico e aqueles com etiologia indeterminada. Essa questão deve ser examinada em amostras maiores para melhor compreender a importância do mecanismo do AVC e a profilaxia secundária.

Incidence of cardioembolic stroke related to atrial fibrillation in Joinville, Brazil / Incidência de acidente vascular encefálico relacionado à fibrilaçao atrial em Joinville, Brasil

Abstract Background Atrial fibrillation (AF) is an important cause of cardioembolic stroke, and population aging has increased its prevalence. Objective To evaluate the incidence of cardioembolic stroke caused by AF in the city of Joinville, Brazil, as well as previous diagnoses and use of medication. Methods Between 2017 and 2020 we extracted data from the population-based Joinville Stroke Registry. Demographic characteristics, diagnosis of AF, and patterns of medication use were collected, and the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) system was used to classify the etiology. Results There were 3,303 cases of ischemic stroke, 593 of which were cardioembolic, and 360 had AF. Of the patients with AF, 258 (71.6%) had a previous diagnosis of the disease, and 102 (28.3%) were newly diagnosed after the stroke. Among patients with a previously-diagnosed AF, 170 (47.2%) were using anticoagulants, and 88 (24.4%) were using other medications. Conclusion During the analyzed period, ischemic stroke caused by AF was a significant burden on the population of Joinville, and a considerable number of patients had undiagnosed or untreated AF.

Resumo Antecedentes A fibrilação atrial (FA) é uma importante causa de acidente vascular cebebral (AVC) cardioembólico, e o envelhecimento populacional aumentou a sua prevalência. Objetivo Avaliar a incidência de AVC cardioembólico causado por FA em Joinville, além dos diagnósticos prévios e do uso de medicamentos. Métodos Entre 2017 e 2020, foram extraídos dados do registro de base populacional de AVC de Joinville. Características demográficas, diagnóstico de FA e padrões de uso de medicamentos foram coletados, e o sistema Trial of ORG 10172 in Acute Stroke Treatment (TOAST) foi utilizado para classificar a etiologia. Resultados Houve 3.303 casos de AVC isquêmico, sendo 593 cardioembólicos e 360 com FA. Dos pacientes com FA, 258 (71,6%) tinham diagnóstico prévio da doença, e 102 (28,3%) foram recém-diagnosticados após o AVC. Entre os pacientes com FA previamente diagnosticada, 170 (47,2%) estavam em uso de anticoagulante, e 88 (24,4%), em uso de outra medicação. Conclusão Durante o período analisado, o AVC isquêmico causado por FA foi um ônus significativo para a população de Joinville, e um número considerável de pacientes apresentava FA não diagnosticada ou não tratada.

Does left atrial appendage morphology and dimension differ amongst etiological stroke subtypes in patients without known atrial fibrillation? Results from the left atrial appendage morphology and dimension assessment by TEE in patients with stroke without known atrial fibrillation (LAMDA-STROKE) study

Context: Complex left atrial appendage (LAA) morphology is increasingly associated with cryptogenic ischemic stroke as compared to cardioembolic stroke due to atrial fibrillation (AF). However, data on such an association in patients with other etiological stroke subtypes in the absence of AF is limited. Aim: The study aimed to assess the LAA morphology, dimension and other echocardiographic parameters by transesophageal echocardiography (TEE) in patients with embolic stroke of undetermined source (ESUS) and compare it with other etiological stroke subtypes without known AF. Methods: This was a single-Centre, observational study involving comparison of echocardiographic parameters including LAA morphology and dimension in ESUS patients (group A; n ¼ 30) with other etiological stroke subtypes i.e., TOAST (Trial of Org 10172 in Acute Stroke Treatment) class I-IV without AF (group B; n ¼ 30). Results: Complex LAA morphology was predominant in group A (18 patients in group A versus 5 patients in group B, p-Value ¼ 0.001). Mean LAA orifice diameter (15.3 þ 3.5 mm in group A versus 17 þ 2.0 mm in group B, p-Value ¼ 0.027) and LAA depth were significantly lower in group A (28.4 þ 6.6 mm in group A versus 31.7 þ 4.3 mm in group B, p-Value ¼ 0.026). Out of these three parameters only complex LAA morphology was found to be independently associated with ESUS [OR ¼ 6.003, 95% CI {1.225e29.417}, p ¼ 0.027]. Conclusion: Complex LAA morphology is a predominant feature in ischemic stroke patients with ESUS and may contribute to an increased risk of stroke in these patients.

Pulmonary arteriovenous malformation and cryptogenic stroke / 国际脑血管病杂志

The relationship between pulmonary arteriovenous malformations (PAVMs) and stroke remains unclear. With the development of imaging technology, studies shows that PAVMs are an important cause of cryptogenic stroke (CS). Most PAVMs are not diagnosed until the onset of stroke. The main pathogenesis of PAVMs-related CS is paradoxical embolism and increased blood viscosity caused by iron deficiency anemia. Antiplatelet therapy and interventional therapy may have a preventive effect on recurrent stroke in such patients. This article summarizes the pathophysiological mechanism, diagnosis and treatment of PAVMs-related CS, hoping to provide new ideas for the diagnosis and treatment of CS.

Cierre de apéndice auricular en fibrilación auricular y alto riesgo de sangrado: serie de casos / Atrial appendage closure in atrial fibrillation and high risk of bleeding: case series

RESUMEN INTRODUCCIÓN: La fibrilación auricular aumenta 5 veces el riesgo de un ataque cerebrovascular de origen cardioembólico. La anticoagulación está indicada para prevención primaria y secundaria de embolismo cerebral. En pacientes con alto riesgo de sangrado no modificable se ha propuesto el cierre de apéndice auricular izquierdo como alternativa a la anticoagulación. MÉTODOS: Serie de casos retrospectiva de pacientes incluidos en el registro ReACTIVE entre los años 2019 y 2020 con diagnóstico de fibrilación auricular, puntaje de CHA2DS2-VASc ≥ 4, HAS BLED ≥ 3 y contraindicación de terapia anticoagulante a largo plazo. Se incluyeron variables demográficas, factores de riesgo, desenlace clínico usando la escala de Rankin modificado y se hizo seguimiento clínico a 3 meses después del procedimiento. RESULTADOS: Se incluyeron 6 pacientes, el 50 % de ellos mujeres, con mediana de edad de 80,8 ± 4,8 años. El 83,3 % presentó antecedente de sangrado mayor bajo consumo de anticoagulantes. En el seguimiento a 90 días, ningún paciente experimentó sangrado ni ataque cerebrovascular, un paciente murió por causas no cardiovasculares, en tanto que el 83,3 % de los pacientes tuvieron un Rankin modificado favorable (0-2). CONCLUSIONES: El cierre de apéndice auricular es una opción terapéutica en pacientes con fibrilación auricular y contraindicación para anticoagulación por alto riesgo de sangrado. Nuestra serie obtuvo resultados similares a los publicados a escala nacional a pesar de incluir pacientes con edad más avanzada. La conformación de equipos interdisciplinarios de corazón y cerebro es útil en la selección de pacientes para esta terapia.

ABSTRACT INTRODUCTION: Atrial fibrillation increases the risk of a cerebrovascular attack of cardioembolic source by 5 times. Anticoagulation is indicated for primary and secondary prevention of cerebral embolism. In patients at high risk of non-modifiable bleeding, closure of the left atrial appendage has been proposed as an alternative to anticoagulation. METHODS: Retrospective case series of patients included in the ReACTIVE registry between 2019 and 2020 with a diagnosis of atrial fibrillation, CHA2DS2-VASc score ≥ 4, HAS-BLED ≥ 3, and long-term anticoagulant therapy contraindication. Demographic variables, risk factors, and clinical outcomes were included using the modified Rankin scale, and clinical follow-up was done three months after the procedure. RESULTS: 6 patients were included, 50 % women, median age 80.8 ± 4.8 years. 83.3 % history of major bleeding under anticoagulant treatment. At the 90-day follow-up, no patient had a bleeding or cerebrovascular attack, one patient died from non-cardiovascular causes, and 83.3 % of the patients had a favorable modified Rankin (0-2). CONCLUSIONS: Atrial appendix closure is a therapeutic option in patients with atrial fibrillation and a contraindication for anticoagulation due to a high risk of bleeding. Our series obtained results like those published at the national level despite including older patients. The formation of interdisciplinary heart and brain teams is helpful in the selection of patients for this therapy.

STUDY OF PATIENTS WITH ATRIAL FIBRILLATION IN VIEW OF ETIOLOGICAL EVALUATION AND CLINICAL PROFILE.

Background : Atrial fibrillation(AF) is the most common sustained arrhythmia encountered inclinical practice,accounting 1/3 of hospital-admissions for arrhythmia and rate of admissions for AFhas risen recently.The principle significance of AF both to patient and healthcare system is fivefoldincreased risk of embolic stroke.Methodology: Electrocardiogram confirmed 100 adult(≥18 years) patients of AF were included inthis study and evaluated clinically.Results: Incidence of AF in India is significantly high in younger age group and in Female(58%) ascompared to Western countries,where AF is more common in old age and in Male(42%).Mostcommon cause of AF is Rheumatic heart disease as compared to Western countries,where IHD is thecommonest cause.The average age of patient having RHD developing AF,in India,is 15-20 yearsearlier than patients from Western countries.Most common complication of AF is Congestive cardiacfailure. Most serious complication of AF is Cardio-embolic stroke.Increase in size of Left Atrium inAF is associated with increased risk of Cardio-embolic stroke.Conclusion: Trials have shown reduction in risk,if patients are adequately anticoagulated.so earlyevaluation and prophylactic treatment can reduce mortality and morbidity in patients of AF.

Anticoagulation and Stroke / Anticoagulação e AVC

Abstract In 2019, the American Heart Association did not recommend the emergent use of anticoagulation to prevent recurrence or progression of acute ischemic stroke. However, its indication in patients with extracranial artery intraluminal thrombus with artery-to-artery cerebral embolization must be analyzed. In this article, we will also discuss other indications of anticoagulation. This treatment could be indicated in patients with ischemic stroke caused by embolization from cervical artery dissection, catastrophic antiphospholipid antibodies syndrome (APS) and some cases of Covid 19. For secondary prevention, anticoagulation is recommended for Cardioembolic stroke such as nonvalvular atrial fibrillation and other cardiopathies, some patients with cervical artery dissection, stroke associated with cancer, and thrombophilia such as APS. The timing to restart anticoagulation after a large ischemic stroke or after a cerebral hemorrhagic transformation always represent a challenge. Even in patients with high risk of thromboembolism it should be delayed at least two weeks, ideal after four weeks.

Resumo Anticoagulação na fase aguda do acidente vascular isquêmico (AVCI) ainda é um tema bastante controverso. Em 2019, a American Heart Association (AHA) não recomendou o uso precoce da anticoagulação para evitar a progressão ou recorrência de AVCIs de grandes artérias. Mas sugere que a anticoagulação em pacientes com AVCI por embolização a partir de trombos intraluminais aderidos a parede de vasos extracranianos fosse analisada. Tanto a antiagregação como anticoagulação são opções terapêuticas nos casos de AVCI por dissecção arterial cervical. Mas em pacientes com AVCI por mecanismo de embolização, a anticoagulação poderia ser indicada. Pacientes com AVCI e sindrome catastrófica por anticorpos antifosfolípides devem ser anticoagulados além de receber tratamento específico. Outra indicação seriam casos de trombofilia como Covid 19. Nesse artigo de revisão será discutida a prevenção secundária de AVCI em situações específicas (AVCI cardioembólico em pacientes com fibrilação atrial não valvular ou outras cardiopatias, AVCI em casos oncológicos, além de outras trombofilias), além do período ideal para se introduzir ou reiniciar a anticoagulação após transformação hemorrágica.

Endovascular treatment of acute ischemic stroke with large vessel occlusion in anterior circulation: cardioembolism versus large artery atherosclerosis / 国际脑血管病杂志

Objective:To investigate the clinical characteristics of acute ischemic stroke with anterior circulation large vessel occlusion caused by cardioembolism (CE) and large artery atherosclerosis (LAA) and the efficacy of endovascular treatment.Methods:Patients with acute ischemic stroke caused by large vessel occlusion in anterior circulation and received endovascular treatment in the Stroke Center of the 971 st Hospital of the PLA Navy from April 2014 to April 2021 were retrospectively enrolled. The etiological classification of stroke was CE or LAA. According to the modified Rankin Scale score at 90 d after onset, the patients were divided into good outcome group (0-2) and poor outcome group (>2). The demographic and clinical data between the groups were compared. Multivariate logistic regression analysis was used to determine the independent influencing factors of clinical outcome. Results:A total of 106 patients were enrollded. Their age was 61.39±13.73 years and 70 (66.0%) were males. Seventy-four patients (69.8%) were in the CE group and 32 (30.2%) were in the LAA group. Sixty-six patients (62.3%) had good outcomes. Univariate analysis showed that there were significant differences in gender, age, smoking, systolic blood pressure, diastolic blood pressure, baseline National Institutes of Health Stroke Scale (NIHSS) score, time from onset to femoral artery puncture, time from puncture to vascular recanalization, and the number of retrieval attempts between the CE group and the LAA group (all P<0.05), and there were no significant differences in the incidences of poor outcome, hemorrhagic transformation, and symptomatic intracranial hemorrhage. There were significant differences in systolic blood pressure, diastolic blood pressure, baseline NIHSS score, time from onset to femoral artery puncture, and blood perfusion grade after treatment between the good outcome group and the poor outcome group (all P<0.05). Multivariable logistic regression analysis showed that higher systolic blood pressure (odds ratio [ OR] 1.046, 95% confidence interval [ CI] 1.014-1.078; P=0.004), higher baseline NIHSS score ( OR 1.117, 95% CI 1.037-1.203; P=0.003), longer time from onset to femoral artery puncture ( OR 1.008, 95% CI 1.001-1.015; P=0.019) and poor blood perfusion after treatment ( OR 8.042, 95% CI 1.532-42.215; P=0.014) were significantly and independently associated with the poor outcomes. Conclusions:Compared with LAA, CE do not increase the risks of hemorrhagic transformation and symptomatic intracranial hemorrhage. The safety and efficacy of the two are similar.

The role of left atrial enlargement and age in the prediction of recurrence in embolic strokes of undetermined source / El papel del crecimiento auricular izquierdo y la edad como predictores de recurrencia en infarto cerebral embólicos de origen indeterminado

Abstract Objectives: Left atrial disease is an independent risk factor for ischemic stroke and can be used to predict atrial fibrillation (AF). We examine whether left atrial enlargement (LAE) could predict stroke recurrence in patients with embolic stroke of undetermined source (ESUS). Materials and methods: Sixty-four patients with a confirmed diagnosis of ESUS were followed for a median of 22 months. Clinical data and echocardiogram findings were recorded. The echocardiogram interpretation was performed centrally and blindly. The Brown ESUS – AF score was used to categorize patients into high (human resource planning [HRP]: score > 2) and low-risk patients (non-HRP score 0-1). Stroke recurrence was the primary outcome. Results: The median age was 62 years (range: 22-85 years); and 33 (51.6%) were men. The median initial NIHSS score was three points (range: 0-27). Twelve (18.8%) patients were categorized as HRP. We found a significant tendency toward recurrence among HRP versus non-HRP patients. Three (25%) HRP versus 2 (3.8%) non-HRP experienced recurrence (OR: 8.3 95% CI 1.2-57; p=0.042); this association was related to severe atrial dilatation (OR: 14.5 95% CI 0.78-277, p = 0.02) and age > 75 years (OR: 12.7 95% CI 1.7-92.2, p = 0.03). We found no differences in recurrence in a univariate analysis. Conclusions: Patients with severe LAE who are 75 years old or older have a significant tendency to experience stroke recurrence.

Resumen Objetivos: La patología atrial izquierda es factor de riesgo independiente para infarto cerebral y puede utilizarse para predecir fibrilación auricular. Examinamos si el crecimiento aurícular izquierdo puede predecir recurrencia en pacientes con infarto embolico de origen indeterminado (ESUS). Materiales y métodos: Sesenta y cuatro pacientes con diagnóstico confirmado de ESUS fueron seguidos por una mediana de seguimiento de 22 meses. Registramos los datos clínicos y ecocardiográficos. La interpretación ecocardiográfica fue centralizada y cegada. La escala de Brown ESUS – AF fue utilizada para categorizar a los pacientes en riesgo alto (HRP puntaje > 2) y bajo riesgo (no-HRP: puntaje 0-1). El descenlace primario fue recurrencia de infarto cerebral. Resultados: Mediana de edad fue de 62 años (rango: 22-85 años); 33 (51.6%) fueron hombres. La mediana inicial de la escala de NIHSS fue de 3 putnos (rango de 0 a 27). 12 (18.8%) pacientes fueron de alto riesgo (HRP) y 52 (81.3%) de bajo riesgo (non- HRP). El grupo HRP mostró tendencia significatica hacia mayor recurrencia. Tres (25%) HRP versus 2 (3.8%) no-HRP experimentaron recurrencia (OR: 8.3 IC 95% 1.2-57; p = 0.042); esta asociación se relacionó con dilatación auricular severa (OR: 14.5 IC 95% 0.78-277, p = 0.02) y edad > 75 años (OR: 12.7 IC 95% 1.7-92.2, p = 0.03). En el análisis multivarioado, no encontramos significativas. Conclusiones: El crecimiento auricular izquierdo severo y la edad mayor de 75 años mostraron tendencia significativa a recurrencia de infarto cerebral.

Comparison of outcomes after thrombectomy in patients with embolic stroke of undetermined source and cardiogenic stroke / 上海交通大学学报（医学版）

Objective: To compare the baseline characteristics and treatment outcomes of mechanical thrombectomy in patients with intracranial arterial occlusion caused by embolic stroke of undetermined source and cardiogenic stroke. Methods: Retrospective analysis was made on ESUS and CS patients in registration databases who received thrombectomy in two stroke centers, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine and Lishui Central Hospital, Zhejiang University from November 2012 to April 2019. T-test and Mann-Whitney U test were used to compare the measurement data, χ2 test and Fisher's exact test were used to compare the counting data, and the independent prognostic risk factors were analyzed by Logistic regression. Results: In all, 117 participants were eventually enrolled, including 30 (25.6%) with ESUS and 87 (74.4%) with CS. Compared with the CS group, the ESUS group was significantly younger (mean ages, 64 years vs 75 years, P=0.003) with lower median baseline NIHSS scores (12 vs. 15, P=0.020), lower median NIHSS scores at 24 h (10 vs 12, P=0.033) and lower median MRS scores at 90 days (2 vs 4, P=0.015). The rates of successful recanalization were similar. Logistic regression analysis showed hypertension (OR=0.264, 95%CI 0.099-0.704, P=0.008) and baseline NIHSS scores (OR=0.758, 95%CI 0.673-0.853, P=0.000) were independent risk factors affecting prognoses. Conclusion: Compared with CS, ESUS patients are relatively younger and have milder neurological dysfunction at onset and better prognoses; however, both groups have high mortality rates. The successful recanalization rates for mechanical thrombectomy are similar. The baseline NIHSS score and hypertension are independent prognostic risk factors.

Embolic stroke of undetermined source (ESUS) cohort of Brazilian patients in a university hospital / Coorte brasileira de pacientes com AVC embólico de fonte indeterminada (ESUS) em um hospital universitário

ABSTRACT Embolic stroke of undetermined source (ESUS) is an important group of cryptogenic strokes that are in evidence due recent ongoing trials. We reviewed medical records at discharge from the stroke unit of all patients who met ESUS criteria and attended our institution between February 2016 and July 2017. Among 550 stroke patients, 51 had ESUS. We found that hypertension (60%), diabetes mellitus (34%), and smoking (36%) were the most prevalent risk factors. The mean National Institutes of Health Stroke Scale (NIHSS) scores were 7 at admission and 4 at discharge, while median scores on the modified Rankin scale were 0 and 2 at admission and discharge, respectively. Our sample had similar ages, risk factors prevalence and NIHSS scores at admission and discharge when compared with European and North American cohorts. Although a small cohort, our study suggests that the ESUS population is similar in countries with different health financing.

RESUMO Acidentes vasculares cerebrais (AVC) embólicos de fonte indeterminada (ESUS) é um grupo importante de pacientes com AVC criptogênico que estão em evidência devido a recentes ensaios clínicos. Foram revisados os prontuários médicos na alta da unidade de AVC de todos os pacientes que preencheram os critérios para ESUS atendidos em nossa instituição entre fevereiro de 2016 e julho de 2017. Entre 550 AVCs, 51 eram pacientes com ESUS. Hipertensão (60%), diabetes mellitus (34%) e tabagismo (36%) foram os fatores de risco mais prevalentes. Os escores médios do National Institutes of Health Stroke Scale (NIHSS) foram 7 na admissão e 4 na alta, enquanto os escores médios na escala de Rankin modificada (mRs) foram 0 e 2 na admissão e alta, respectivamente. Nossa amostra teve idade, prevalência de fatores de risco, escores NIHSS na admissão e alta, quando comparados com coortes europeias e norte-americanas semelhantes. Apesar de ser uma pequena coorte, nosso estudo sugere que a população ESUS é semelhante em países com diferentes níveis de financiamento em saúde.

Embolic Stroke of Undetermined Source Accompanied by Lipomatous Hypertrophy of Interatrial Septum

No abstract available.

Simultaneous Occurrence of Spontaneous Coronary Artery Dissection and Embolic Stroke.

Acute coronary syndrome (ACS) due to spontaneous coronary artery dissection (SCAD) is rare. Further, concurrent ACS with a cerebrovascular accident is improbable, but possible. We report a case of a young man, with a history of Hodgkin’s lymphoma treated with a combination of chemotherapy and radiotherapy ten years ago, presented with acute coronary syndrome caused by an extensive dissection of the right coronary artery, together with acute ischemic stroke. Survivors of Hodgkin’s lymphoma are at increased risk for cardiovascular complications due to radiation, which can expedite atherosclerosis and can, eventually, give rise to dissection and cerebrovascular disease, as exemplified in our case. This case report and review outlines the incidence, epidemiology, causes, pathophysiology, diagnosis and treatment of spontaneous coronary artery dissection. Our case report is a remainder to clinicians to be mindful of concomitant occurrence of these two conditions and highlights the significant impact the treatment of each has on the other, especially when the literature does not have clear recommendations about simultaneous management. Spontaneous coronary artery dissection with concomitant ischemic cerebrovascular stroke poses a therapeutic dilemma and requires a multi-disciplinary team to appropriately manage the patient.

A Case of Surgical Removal of Left Ventricular Thrombus and Biventricular Pacing with Alcoholic Cardiomyopathy / 日本心臓血管外科学会雑誌

A 62-year-old man had suffered from massive pedal edema, dyspnea and sinus bradycardia for 10 days. He had been heavy drinker for over 20 years. He was transferred to our hospital with severe heart failure. Echocardiography showed severe diffuse hypokinesis of left ventricular wall motion (EF20%) with dyssynchrony, and thrombus in the left ventricular apex. Under a diagnosis of LV thrombus due to severe heart failure, we made a plan for an emergency open heart surgery, but it could not be performed because of initial cardiogenic embolic stroke. Therefore, we waited for 2 weeks while performing anticoagulation therapy. The removal of LV thrombus and atrio-biventricular pacing for heart failure due to dyssynchrony were performed 2 weeks later. The pathological specimen of myocardium showed marked fibrous and hypertrophic change, which were similar to idiopathic dilated cardiomyopathy. Alcoholic cardiomyopathy due to alcohol intake for many years is similar to a clinical image of dilated cardiomyopathy, but its clinical prognosis by abstinence is not bad. In this case we performed an urgent open heart surgery due to cardiogenic embolic stroke, but must be essentially performed as an emergency operation. Postoperative course was uneventful and he was discharged 21 days after open heart surgery without any complications.

Mechanical cardiac remodeling and new-onset atrial fibrillation in long-term follow-up of subjects with chronic Chagas' disease

Atrial fibrillation (AF) affects subjects with Chagas' disease and is an indicator of poor prognosis. We investigated clinical, echocardiographic and electrocardiographic variables of Chagas' disease in a long-term longitudinal study as predictors of a new-onset AF episode lasting >24 h, nonfatal embolic stroke and cardiac death. Fifty adult outpatients (34 to 74 years old, 62 percent females) staged according to the Los Andes classification were enrolled. During a follow-up of (mean ± SD) 84.2 ± 39.0 months, 9 subjects developed AF (incidence: 3.3 ± 1.0 percent/year), 5 had nonfatal stroke (incidence: 1.3 ± 1.0 percent/year), and nine died (mortality rate: 2.3 ± 0.8 percent/year). The progression rate of left ventricular mass and left ventricular ejection fraction was significantly greater in subjects who experienced AF (16.4 ± 20.0 g/year and -8.6 ± 7.6 percent/year, respectively) than in those who did not (8.2 ± 8.4 g/year; P = 0.03, and -3.0 ± 2.5 percent/year; P = 0.04, respectively). In univariate analysis, left atrial diameter ≥3.2 cm (P = 0.002), pulmonary arterial hypertension (P = 0.035), frequent premature supraventricular and ventricular contraction counts/24 h (P = 0.005 and P = 0.007, respectively), ventricular couplets/24 h (P = 0.002), and ventricular tachycardia (P = 0.004) were long-term predictors of AF. P-wave signal-averaged ECG revealed a limited long-term predictive value for AF. In chronic Chagas' disease, large left atrial diameter, pulmonary arterial hypertension, frequent supraventricular and ventricular premature beats, and ventricular tachycardia are long-term predictors of AF. The rate of left ventricular mass enlargement and systolic function deterioration impact AF incidence in this population.

Types of Thromboembolic Complications in Coil Embolization for Intracerebral Aneurysms and Management

OBJECTIVE: We describe our clinical experiences and outcomes in patients who had thromboembolic complications occurring during endovascular treatment of intracerebral aneurysms with a review of the literature. The types of thromboembolic complications were divided and the treatment modalities for each type were described. METHODS: Between August 2004 and March 2009 we performed endovascular embolization with Guglielmi detachable coils for 173 patients with 189 cerebral aneurysms, including ruptured and unruptured aneurysms at our hospital. Sixty-eight patients were males and 105 patients were females. The age of patients ranged from 22-82 years (average, 58.8 years). We retrospectively evaluated this group with regard to complication rates and outcomes. The types of thromboembolic complications were classified into the following three categories: mechanical obstruction, distal embolic stroke, and stent-induced complications, which corresponded to types I, II, and III, respectively. A comparison of the clinical results was made for each type of complication. RESULTS: Only eight patients had a thromboembolic complication during or after a procedure (4.6%). Of the eight patients, two had a mechanical obstruction as the causative factor; the other three patients had distal embolic stroke as the causative factor. The remaining three patients had stent-induced complications. In cases of mechanical obstruction, recanalization occurred due to the use of intra-arterial thrombolytic agents in one of two patients. Nevertheless, a poor prognosis was seen. In the cases of stent-induced complications, in one of three patients in whom a thrombus developed following stent insertion, a middle cerebral artery territory infarct developed with a poor prognosis despite the use of wiring and an intra-arterial thrombolytic agent. In the cases of distal embolic stroke, all three patients achieved good results following the use of antiplatelet agents. CONCLUSION: Treatment for thromboemboic complications due to mechanical obstruction and stent-induced complications include antiplatelet and intra-arterial thrombolytic agents; however, this cannot guarantee a sufficient extent of effectiveness. Therefore, active treatments, such as balloon angioplasty, stent insertion, and clot extraction, are helpful.

A proposito de un caso clínico: infarto simultaneo cardiaco y cerebral, en el curso de endocarditis infecciosa / Purposely of s case report: simultaneous cardiac and cerebral infarction, in the course of infectious endocarditis

Se trata de un caso de paciente masculino, de 58 años de edad, atendido de emergencia en el Intituto Nacional de Torax por presentar un cuadro clínico inusual de Infarto Agudo de Miocardio asociado contemporáneamente a infarto cerebral como complicación de embolismo séptico procedente de vegetaciones de la válvula mitral en el curso de Endocarditis Infecciosa, no diagnosticada previamente. Es un caso de alto riesgo de mortalidad que evolucionó satisfactoriamente mediante estrategia de tratamiento combinado de Antibioticoterapia parenteral, tratamiento invasivo con cateterismo cardiaco y Angioplastia Coronaria Primaria, y tratamiento quirúrgico con circulación extracorpórea de Cambio Valvular Mitral.

A clinical case of a 58 years old patient is described, the patient wasadmitted as an Emergency to the Instituto Nacional de Tórax, with anunusual presentation of both Acute myocardial Infarction and CerebralEmbolic Stroke as a complication of septic embolism associated withmitral valve vegetations in the course of Infective Endocarditis thatwas not previously diagnosed. This is a high mortality risk clinicalcase, that evolved to full recovery with combined treatment strategyincluding full antibiotic therapy, cardiac catheterization and primarycoronnary angioplasty, and surgical mitral valve replacement.