Advances in Management of the Stroke Etiology One-Percenters.

PURPOSE OF REVIEW: Uncommon causes of stroke merit specific attention; when clinicians have less common etiologies of stoke in mind, the diagnosis may come more easily. This is key, as optimal management will in many cases differs significantly from "standard" care. RECENT FINDINGS: Randomized controlled trials (RCT) on the best medical therapy in the treatment of cervical artery dissection (CeAD) have demonstrated low rates of ischemia with both antiplatelet and vitamin K antagonism. RCT evidence supports the use of anticoagulation with vitamin K antagonism in "high-risk" patients with antiphospholipid antibody syndrome (APLAS), and there is new evidence supporting the utilization of direct oral anticoagulation in malignancy-associated thrombosis. Migraine with aura has been more conclusively linked not only with increased risk of ischemic and hemorrhagic stroke, but also with cardiovascular mortality. Recent literature has surprisingly not provided support the utilization of L-arginine in the treatment of patients with mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS); however, there is evidence at this time that support use of enzyme replacement in patients with Fabry disease. Additional triggers for reversible cerebral vasoconstriction syndrome (RCVS) have been identified, such as capsaicin. Imaging of cerebral blood vessel walls utilizing contrast-enhanced MRA is an emerging modality that may ultimately prove to be very useful in the evaluation of patients with uncommon causes of stroke. A plethora of associations between cerebrovascular disease and COVID-19 have been described. Where pertinent, authors provide additional tips and guidance. Less commonly encountered conditions with updates in diagnosis, and management along with clinical tips are reviewed.

Covid-19 vaccine (covishield) heralding Moyamoya angiopathy

Indroduction: Thrombotic complications leading to cerebrovascular events occuring in conjunction with Covid-19 vaccination though rare, is well-documented. Moyamoya Angiopathy is a progressive intracranial vasculopathy leading to recurrent strokes. Case presentation: We present two index cases of young patient presenting with stroke and TIA following Covid-19 vaccination (COVISHIELD) leading to unmasking of Moyamoya Angiopathy. Conclusion(s): Arterial stroke following Covid-19 vaccination is documented, but uncommon. However, in the background of a vasculopathy, it may not be so rare. Moyamoya Angiopathy has been closely studied in the model of inflammatory pathophysiology in genetically predisposed patients leading to progressive vaso-occlusive disease. Few reports of Covid-19 infection potentiating Moyamoya Angiopathy symptoms are also documented. Thus, as an extrapolation of the inflammatory etiopathogenesis of Moyamoya Angiopathy, Covid-19 vaccination can similarly affect the Moyamoya symptomatology. These two index cases open new lines of enquiry regarding the interplay of Covid-19 vaccination and neurological destabilization in patients with underlying vasculopathy of inflammatory pathophysiology.Copyright © 2022

Tracheotomy In Patients With Covid-19

Relevance. The coronavirus rush, which has appeared since December 2019, has an impact on economic, medical, and social development in all countries of the world. There are still no standard diagnostic and therapeutic plans aimed at limiting this infection. Purpose. To determine the therapeutic role of tracheostomy with patients with coronavirus infection. Material. The prospective study of 100 patients with coronavirus infection was carried out on the basis of State Budgetary Healthcare Institution "Interdistrict Multidisciplinary Hospital" in Nartkala city. When patients were admitted to the clinic, they were randomized into 2 groups depending on the therapy: the first group (comparison, n=50) - patients received traditional therapy in intensive care;the second (main, n=50) group - patients underwent tracheostomy in addition to standard therapy. The average age was 56.2+/-4.8 years. The women's average age was 55 years (55.0%), and the men's - 45 years (45.0%). Methods. Determination of the syndrome of endogenous intoxication, taxation of lipid peroxidation intensification. The local microcirculation was investigated by the apparatus LAKK-02. The activity of the coagulation-lytic blood system was found by thrombelastograph TEG 5000. Results. Early COVID-19 infection demonstrates signs of intoxication, oxidative depression, phospholipase activity, microcirculatory and hemostatic disorders. These changes were the cause of the development of life-threatening complications (neurological, pulmonary, cardiac, etc.). They were associated with the type of treatment. Traditional treatment and the use of mask oxygen turned out to be ineffective, since the homeostasis system disorders remained throughout the investigation period. The inclusion of tracheostomy in traditional therapy makes it possible to quickly improve the course of pathology as it purposefully affects the pathogenetic links of the homeostasis system. Conclusion. The use of tracheostomy in the scheme of standard treatment of coronavirus infection allows improving the effectiveness of general therapy of COVID-19 patients, especially with severe forms.Copyright © 2023, Codon Publications. All rights reserved.

COVID-19-induced vascular angiopathy: CTPA signs in critically ill patients other than acute pulmonary embolism and high-lung opacity scores

BackgroundVascular angiopathy is suggested to be the major cause of silent hypoxia among COVID-19 patients without severe parenchymal involvement. However, pulmonologists and clinicians in intensive care units become confused when they encounter acute respiratory deterioration with neither severe parenchymal lung involvement nor acute pulmonary embolism. Other radiological vascular signs might solve this confusion. This study investigated other indirect vascular angiopathy signs on CT pulmonary angiography (CTPA) and involved a novel statistical analysis that was performed to determine the significance of associations between these signs and the CT opacity score of the pathological lung volume, which is calculated by an artificial intelligence system.ResultsThe study was conducted retrospectively, during September and October 2020, on 73 patients with critical COVID-19 who were admitted to the ICU with progressive dyspnea and low O2 saturation on room air (PaO2 < 93%). They included 53 males and 20 females (73%:27%), and their age ranged from 18 to 88 years (mean ± SD=53.3 ± 13.5). CT-pulmonary angiography was performed for all patients, and an artificial intelligence system was utilized to quantitatively assess the diseased lung volume. The radiological data were analyzed by three expert consultant radiologists to reach consensus. A low CT opacity score (≤10) was found in 18 patients (24.7%), while a high CT opacity score (>10) was found in 55 patients (75.3%). Pulmonary embolism was found in 24 patients (32.9%);three of them had low CT opacity scores. Four other indirect vasculopathy CTPA signs were identified: (1) pulmonary vascular enlargement (57 patients—78.1%), (2) pulmonary hypertension (14 patients—19.2%), (3) vascular tree-in-bud pattern (10 patients—13.7%), and (4) pulmonary infarction (three patients—4.1%). There were no significant associations between these signs and the CT opacity score (0.3205–0.7551, all >0.05). Furthermore, both pulmonary vascular enlargement and the vascular tree-in-bud sign were found in patients without pulmonary embolism and low CT-severity scores (13/15–86.7% and 2/15–13.3%, respectively).ConclusionPulmonary vascular enlargement or, less commonly, vascular tree-in-bud pattern are both indirect vascular angiopathy signs on CTPA that can explain the respiratory deterioration which complicates COVID-19 in the absence of severe parenchymal involvement or acute pulmonary embolism.

A case of cerebral amyloid angiopathy related inflammation after vaccination against SARS-CoV-2

Background: Cerebral amyloid angiopathy related inflammation (CAA-RI) is a neuroinflammatory disease that is associated with perivascular amyloid- deposition. Case presentation: A middle-aged woman with a remote history of autoimmune disorders presented with unilateral migraine headaches, dizziness, unsteadiness, and fogginess 36 hours after administration of mRNA vaccine against SARS-CoV-2. Initially, unilateral leptomeningeal enhancement on MRI on the same side of headaches raised suspicion for leptomeningeal involvement of her known cutaneous T-cell lymphoma in remission. After two relatively unremarkable CSF analyses, she underwent a brain biopsy which showed amyloid deposits in vessels instead of lymphomatous infiltration. She was diagnosed with CAA-RI, and the headache and cognitive symptoms responded well to high-dose corticosteroids with a slow taper. Discussion/conclusion: We review the clinical literature of CAA-RI and its potential association with amyloid-related imaging abnormalities (ARIA) after administration of immunotherapy against amyloid.Copyright © 2022

IDF21-0587 Correlation between glycemic profile parameters and chronic complications in patients with diabetic heart disease

Background: Glycemic imbalance has long been recognized as a major vascular risk factor, and in the can be considered an authentic vascular condition that accelerates the development of chronic complications and major cardiovascular events in diabetics. Aim: The main aim of this study is to determine the correlation between the deferential glycemic profile parameters in order to assess the linkage of these parameters with cardiovascular risk score and chronic complications. Method: During this Covid pandemic, a cross-sectional descriptive and analytical study was included 384 Algerian diabetic patients (189 men, 205 women) with a 9-month follow-up. The diagnostic criteria for diabetes have been defined according to FID and WHO guidelines. Fasting blood sugar levels, GPP and HbA1c, prevalence of chronic complications and cardiovascular risk score were evaluated. Multifactor statistical analysis was performed by Software R studio (Package for Social science software), significance was set at p < 0,05. Results: The mean ± SD age of the patients was 61.28 ± 10.04 with mean fasting blood sugar (61.28 ± 10.04), PPG (3.59 ± 1.02) and HbA1c (8.67 ± 1.64%). PPG and FPG are positively and significantly correlated with HbA1c (regression curves;Figure 1) with a stronger correlation between FPG and HbA1c (r = 0.698). A significant association between Hb1Ac and cardiovascular risk score was noted in patients at very high risk and those at high risk (p-value <10-3). This clinical adherence was the object of studying the multifactorial relationship between Hb1Ac, dyslipidemia and BMI, the correlation of which was significantly positive with r = 0.852. In view of these results and the emergence of significant links, the correlational study by the application of the Pearson test between the variabilities studied, the risk score and the chronic complications shows that there is a very strong association between PPG, Hb1Ac, cardiovascular risk score and macroangiopathy complication. Likewise, the correlation was also positive but moderately significant between FPG, Hb1Ac, and microangiopathy complications. (Correlation matrix in Figure 2). Discussion: The HbA1c is the essential tool for monitoring diabetic patients, its level reflecting glycemic equilibration. It is widely accepted that the glycemic balance of diabetic patients is a complex “alchemy” involving both changes in fasting blood sugar and changes in postprandial blood glucose. The study demonstrated the link between these three parameters and determined its relationship to chronic complications. In this way, glycemic balancing reduces the micro-vascular complications of diabetic patients.

A Case of Cerebral Amyloid Angiopathy Related Inflammation After Vaccination Against SARS-CoV-2

Background Cerebral amyloid angiopathy related inflammation (CAA-RI) is a neuroinflammatory disease that is associated with perivascular amyloid- deposition. Case Presentation A middle-aged woman with a remote history of autoimmune disorders presented with unilateral migraine headaches, dizziness, unsteadiness, and fogginess 36 hours after administration of mRNA vaccine against SARS-CoV-2. Initially, unilateral leptomeningeal enhancement on MRI on the same side of headaches raised suspicion for leptomeningeal involvement of her known cutaneous T-cell lymphoma in remission. After two relatively unremarkable CSF analyses, she underwent a brain biopsy which showed amyloid deposits in vessels instead of lymphomatous infiltration. She was diagnosed with CAA-RI, and the headache and cognitive symptoms responded well to high-dose corticosteroids with a slow taper. Discussion/Conclusion We review the clinical literature of CAA-RI and its potential association with amyloid-related imaging abnormalities (ARIA) after administration of immunotherapy against amyloid.

The Plasma Level of Interleukin-1ß Can Be a Biomarker of Angiopathy in Systemic Chronic Active Epstein-Barr Virus Infection.

Systemic chronic active Epstein-Barr virus infection (sCAEBV) is an EBV-positive T- or NK-cell neoplasm revealing persistent systemic inflammation. Twenty-five percent of sCAEBV patients accompany angiopathy. It is crucial to clarify the mechanisms of angiopathy development in sCAEBV because angiopathy is one of the main causes of death. Interleukin-1ß (IL-1ß) is reported to be involved in angiopathy onset. We investigated if IL-1ß plays a role as the inducer of angiopathy of sCAEBV. We detected elevated IL-1ß levels in four out of 17 sCAEBV patient's plasma. Interestingly, three out of the four had clinically associated angiopathy. None of the other patients with undetectable level of IL-1ß had angiopathy. In all patients with high plasma levels of IL-1ß and vascular lesions, EBV-infected cells were CD4-positive T cells. In one patient with high plasma IL-1ß, the level of IL-1ß mRNA of the monocytes was 17.2 times higher than the level of the same patient's EBV-infected cells in peripheral blood. In Ea.hy926 cells, which are the models of vascular endothelial cells, IL-1ß inhibited the proliferation and induced the surface coagulation activity. IL-1ß is a potent biomarker and a potent therapeutic target to treat sCAEBV accompanying angiopathy.

Diffusion tensor tractography of the fornix in cerebral amyloid angiopathy, mild cognitive impairment and Alzheimer's disease.

PURPOSE: Cerebral amyloid angiopathy (CAA) is a common neuropathological finding and clinical entity that occurs independently and with co-existent Alzheimer's disease (AD) and small vessel disease. We compared diffusion tensor imaging (DTI) metrics of the fornix, the primary efferent tract of the hippocampus between CAA, AD and Mild Cognitive Impairment (MCI) and healthy controls. METHODS: Sixty-eight healthy controls, 32 CAA, 21 AD, and 26 MCI patients were recruited at two centers. Diffusion tensor images were acquired at 3 T with high spatial resolution and fluid-attenuated inversion recovery (FLAIR) to suppress cerebrospinal fluid (CSF) and minimize partial volume effects on the fornix. The fornix was delineated with deterministic tractography to yield mean diffusivity (MD), axial diffusivity (AXD), radial diffusivity (RD), fractional anisotropy (FA) and tract volume. Volumetric measurements of the hippocampus, thalamus, and lateral ventricles were obtained using T1-weighted MRI. RESULTS: Diffusivity (MD, AXD, and RD) of the fornix was highest in AD followed by CAA compared to controls; the MCI group was not significantly different from controls. FA was similar between groups. Fornix tract volume was âˆ¼ 30% lower for all three patient groups compared to controls, but not significantly different between the patient groups. Thalamic and hippocampal volumes were preserved in CAA, but lower in AD and MCI compared to controls. Lateral ventricular volumes were increased in CAA, AD and MCI. Global cognition, memory, and executive function all correlated negatively with fornix diffusivity across the combined clinical group. CONCLUSION: There were significant diffusion changes of the fornix in CAA, AD and MCI compared to controls, despite relatively intact thalamic and hippocampal volumes in CAA, suggesting the mechanisms for fornix diffusion abnormalities may differ in CAA compared to AD and MCI.

Covid-19 vaccine (covishield) heralding moyamoya angiopathy

Indroduction Thrombotic complications leading to cerebrovascular events occuring in conjunction with Covid-19 vaccination though rare, is well-documented. Moyamoya Angiopathy is a progressive intracranial vasculopathy leading to recurrent strokes. Case presentation We present two index cases of young patient presenting with stroke and TIA following Covid-19 vaccination (COVISHIELD) leading to unmasking of Moyamoya Angiopathy. Conclusion Arterial stroke following Covid-19 vaccination is documented, but uncommon. However, in the background of a vasculopathy, it may not be so rare. Moyamoya Angiopathy has been closely studied in the model of inflammatory pathophysiology in genetically predisposed patients leading to progressive vaso-occlusive disease. Few reports of Covid-19 infection potentiating Moyamoya Angiopathy symptoms are also documented. Thus, as an extrapolation of the inflammatory etiopathogenesis of Moyamoya Angiopathy, Covid-19 vaccination can similarly affect the Moyamoya symptomatology. These two index cases open new lines of enquiry regarding the interplay of Covid-19 vaccination and neurological destabilization in patients with underlying vasculopathy of inflammatory pathophysiology.

Impact of COVID-19 pandemic in natural course of Moyamoya Angiopathy: an experience from tertiary-care-center in India.

BACKGROUND: COVID-19 mediated immune dysregulation and cytokine storm can precipitate and aggravate Moyamoya angiopathy (MMA), influencing its disease course. This index study was undertaken to prospectively evaluate the status of neurological symptoms of MMA in relation to COVID-19 affection. METHODOLOGY AND RESULTS: Follow-up MMA patients of institute's Stroke-clinic were telephonically interview from 24th March to 30th September, 2020. The first call familiarized them with COVID-19 symptoms and neurological manifestations of MMA, followed by monthly-calls with predesigned questionnaire. Patients with suggestion of COVID-19 underwent nasopharyngeal-swab-testing for COVID-19 Reverse transcription-polymerase chain reaction (RT-PCR) positive cases were subjected to antibody levels for COVID-19 Enzyme-linked immunoassay (ELISA) 8-12 weeks after recovery. During symptomatic phase till 14 days of asymptomatic, they were contacted daily/alternate day. Any new onset/worsening of neurological symptoms were noted. The baseline clinico-radiological details were obtained from stroke-clinic registery. Subsequently, all data were analyzed and compared using descriptive statistics. Seventy four of 104 MMA patients could be contacted and enrolled. The mean age, time since last follow-up and compliance to previously prescribed medication were 23.5 ± 16.1 years, 9.2 ± 1.7 months and 90.5% (n = 67), respectively. Aggravation/new onset neurological symptom were seen in 64.3% (n = 9) of COVID-19 positive MMA (n = 14), of which 8 were seen among the 11 pediatric COVID-19 positive MMA [(Transient ischemic attacks) TIA-4, TIA with headache-1, seizure-2, stroke causing mortality-1]. CONCLUSION: COVID-19 infection can potentiate MMA causing significant morbidity and mortality, especially in children. Providing optimal care for severe diseases (such as MMA) in developing countries during pandemic remains a challenge.

COVID-19-associated thrombotic angiopathy improved after plasma exchange.

Utilization of therapeutic plasma exchange in select patients with COVID-19 microangiopathy may provide useful treatment by modulation of inflammatory cytokines and coagulation cascade to maintain homeostasis.

Multidisciplinary Approaches for Transthyretin Amyloidosis.

Amyloidosis caused by systemic deposition of transthyretin (TTR) is called ATTR amyloidosis and mainly includes hereditary ATTR (ATTRv) amyloidosis and wild-type ATTR (ATTRwt) amyloidosis. Until recently, ATTRv amyloidosis had been considered a disease in the field of neurology because neuropathic symptoms predominated in patients described in early reports, whereas advances in diagnostic techniques and increased recognition of this disease revealed the presence of patients with cardiomyopathy as a predominant feature. In contrast, ATTRwt amyloidosis has been considered a disease in the field of cardiology. However, recent studies have suggested that some of the patients with ATTRwt amyloidosis present tenosynovial tissue complications, particularly carpal tunnel syndrome, as an initial manifestation of amyloidosis, necessitating an awareness of this disease among neurologists and orthopedists. Although histopathological confirmation of amyloid deposits has traditionally been considered mandatory for the diagnosis of ATTR amyloidosis, the development of noninvasive imaging techniques in the field of cardiology, such as echocardiography, magnetic resonance imaging, and nuclear imaging, enabled nonbiopsy diagnosis of this disease. The mechanisms underlying characteristic cardiac imaging findings have been deciphered by histopathological studies. Novel disease-modifying therapies for ATTR amyloidosis, such as TTR stabilizers, short interfering RNA, and antisense oligonucleotides, were initially approved for ATTRv amyloidosis patients with polyneuropathy. However, the indications for the use of these disease-modifying therapies gradually widened to include ATTRv and ATTRwt amyloidosis patients with cardiomyopathy. Since the coronavirus disease 2019 (COVID-19) pandemic, which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, occurred, the minimization of hospital visits and telemedicine have become increasingly important. As older age and cardiovascular disease are major factors associated with increased disease severity and mortality of COVID-19, many ATTR amyloidosis patients are at increased risk of disease aggravation when they are infected with SARS-CoV-2. From this viewpoint, close interspecialty communication to determine the optimal interval of evaluation is needed for the management of patients with ATTR amyloidosis.

Portal vein thrombosis in COVID-19 infection.

BACKGROUND: The COVID-19 pandemic has rapidly spread worldwide. As it is a novel disease, we have less experience in its possible appearances. Predominantly affecting the respiratory tract, about 20-43% patients also present with extrapulmonary manifestations such as coagulation disorders with thrombotic angiopathy. CASE PRESENTATION: In our institution, a patient presented to the emergency department with acute abdominal pain which was caused by portal vein thrombosis. As a COVID-19 nasopharyngeal antigen swab few days earlier was negative, we performed several tests to find out its etiology. After all tests were inconclusive and the patient suffered flu-like symptoms 2 weeks before, we repeated COVID-19 molecular testing and received a positive test result. The patient was treated symptomatically and received therapeutic anticoagulation. CONCLUSION: A COVID-19 infection can also be present without typical pulmonary symptoms. In patients with severe abdominal pain and new diagnosed portal vein thrombosis, it is important to think of a COVID-19 infection. Also, the reliability of antigen nasopharyngeal swab should be considered critically, especially if performed wrongly. We recommended to perform molecular tests when in doubt. After the diagnosis of portal vein thrombosis, immediate anticoagulation is recommended to reduce the risk of further complications like intestinal infarction.

Microvascular Angiopathic Consequences of COVID-19.

The coronavirus disease-2019 (COVID-19) pandemic has rapidly spread across the world. The disease is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which first appeared in Wuhan, China in December, 2019. Ever increasing data is continuing to emerge about the impact of COVID-19 on cardiovascular tissue and other organ system. Clinical features associated with COVID-19 suggest that endothelial cell dysfunction and microvascular thrombosis are to a large extent contributing to resultant multi-organ complications. This review is aimed at highlighting the critical aspects associated with COVID-19 and its presumed microvascular angiopathic consequences on the cardiovascular system leading to multi-organ dysfunction.

Hemorrhagic stroke and COVID-19 infection: Coincidence or causality?

Amyloid Protein Precursor gene duplication is a rare cause of early-onset Alzheimer's disease that can be associated with Cerebral Amyloid Angiopathy. This condition predisposes cerebrovascular events, specifically, intracerebral hemorrhagic stroke. This report describes a case of first-time intracerebral hemorrhage in a patient with APP gene duplication during SARS-CoV-2 infection, a typically pro-thrombotic and pro-inflammatory condition, as a possible trigger for this condition.