Superior Cerebellar Artery Dissection in a Patient Diagnosed with Reversible Cerebral Vasoconstriction Syndrome: A Case Report

Arterial dissection is an uncommon complication of reversible cerebral vasocon-striction syndrome (RCVS). We describe the case of a 35-year-old woman with a migraine history who presented with recurrent thunderclap headache and focal neurological signs, including right hemiataxia. She had been diagnosed with COVID-19 disease two weeks earlier. Neuroimaging revealed multifocal stenosis of the posterior circulation arteries and dissection of the right superior cerebellar artery. She improved significantly throughout her one-week hospitalization and maintained only mild ataxia. The interplay between COVID-19 disease, RCVS, and arterial dissection requires further investigation.Copyright © Author(s) (or their employer(s)) and Sinapse 2022.

VESTIBULAR DYSFUNCTIONS IN CHRONIC BRAIN ISCHEMIA IN THE POST COVID PERIOD.

OBJECTIVE: The aim: The aim of the study is the clinical-pathogenetic reasoning of vestibular dysfunctions (VD) development against the background of chronic brain ischemia in the presence of degenerative changes in the cervical spine (CS) in the post COVID period. PATIENTS AND METHODS: Materials and methods: 82 patients, in the conditions of the clinical base of the Odessa National Medical University in 2019-2021 were examined. Group I with VD against the background of chronic brain ischemia (CBI) at the compensated phase; Group II with VD against the background of CBI at the subcom¬pensated phase (33 men; 49 women), aged from 18 to 55 years. The control group (CG) consisted of 20 patients of the corresponding gender and age. The condition of the state of the autonomic nervous system, vestibular functions, cervical spine, cerebral arteries and emotional condition were examined. RESULTS: Results: Vestibulo-ataxic disorders were higher compared to CG and increased along with the degree of brain damage. An important aspect of the development of VD is autonomic dysfunction against the background of pathological autonomic characteristics with predominant parasympathetic orientation of autonomic tone, especially in the case of insufficiency of autonomic recativity (AR) and pathological autonomic support of activity. Such changes significantly increased in the presence of subcompensation of CBI. The correlation between psychoemotional disorders and changes in autonomic characteristics with VD against the background of CBI with initial regularities depending on the degree of brain damage was defined. The progression of CBI is facilitated by coronavirus infection and manifested in autonomic and psychoemotional dysfunctions. A characteristic hemodynamic feature in groups with compensated and subcompensated CBI is the presence of reduced perfusion in basilar (BA) and vertebral (VA) arteries. Changes in cerebral vascular reactivity with a decrease in cerebrovascular reactivity indicators were characteristic of the subcompensated phase of CBI. Hyperactivity to rotational functional loads in both clinical groups has a high correlation with the presence of stair descent and, to a lesser extent, isolated instability in CS. CONCLUSION: Conclusions: 1. The occurrence of VD is facilitated by the presence of autonomic dysfunction and degenerative-dystrophic changes in the CS, especially in case of subcompensation of CBI. 2. Psychoemotional changes were a characteristic feature of patients with VD against the background of CBI and had certain regularities depending on the phase of CBI. 3. Suffered coronavirus infection contributes to the progression of VD and further decompensation of CBI due to direct damage to the autonomic and vascular systems of the brain. 4. Changes in cerebral hemodynamics in the form of reduced perfusion in BA and VA, a decrease in cerebrovascular reactivity, and an increase in reactivity to rotational functional load were determined in patients with VD against the background of subcompensated CBI.

SARS-CoV-2 and Stroke in a New York Healthcare System

Background and Purpose: With the spread of coronavirus disease 2019 (COVID-19) during the current worldwide pandemic, there is mounting evidence that patients affected by the illness may develop clinically significant coagulopathy with thromboembolic complications including ischemic stroke. However, there is limited data on the clinical characteristics, stroke mechanism, and outcomes of patients who have a stroke and COVID-19. Method(s): We conducted a retrospective cohort study of consecutive patients with ischemic stroke who were hospitalized between March 15, 2020, and April 19, 2020, within a major health system in New York, the current global epicenter of the pandemic. We compared the clinical characteristics of stroke patients with a concurrent diagnosis of COVID-19 to stroke patients without COVID-19 (contemporary controls). In addition, we compared patients to a historical cohort of patients with ischemic stroke discharged from our hospital system between March 15, 2019, and April 15, 2019 (historical controls). Result(s): During the study period in 2020, out of 3556 hospitalized patients with diagnosis of COVID-19 infection, 32 patients (0.9%) had imaging proven ischemic stroke. Cryptogenic stroke was more common in patients with COVID-19 (65.6%) as compared to contemporary controls (30.4%, P=0.003) and historical controls (25.0%, P<0.001). When compared with contemporary controls, COVID-19 positive patients had higher admission National Institutes of Health Stroke Scale score and higher peak D-dimer levels. When compared with historical controls, COVID-19 positive patients were more likely to be younger men with elevated troponin, higher admission National Institutes of Health Stroke Scale score, and higher erythrocyte sedimentation rate. Patients with COVID-19 and stroke had significantly higher mortality than historical and contemporary controls. Conclusion(s): We observed a low rate of imaging-confirmed ischemic stroke in hospitalized patients with COVID-19. Most strokes were cryptogenic, possibly related to an acquired hypercoagulability, and mortality was increased. Studies are needed to determine the utility of therapeutic anticoagulation for stroke and other thrombotic event prevention in patients with COVID-19.Copyright © 2020 Lippincott Williams and Wilkins. All rights reserved.

A Series of Catastrophic Events

Case report - Introduction: Catastrophic antiphospholipid syndrome (CAPS) is a rare, life-threatening disease occurring in up to 1% of antiphospholipid syndrome (APS) cases. It was first defined in 1992 and remains a difficult to treat entity with a mortality rate of 37%. We describe a patient with systemic lupus erythematosus (SLE) and CAPS presenting with simultaneous multi-organ injuries who was successfully managed with 'triple' therapy including cyclophosphamide. Case report - Case description: A 42-year-old female presented to her local hospital with chest pain and worsening vision. She had a background of SLE, triple antibody-positive APS (previous DVT, pregnancy loss and strokes), hypertension, a metallic mitral valve, a previous myocardial infarction and pre-existing visual impairment due to a prior intra-cerebral bleed related to anticoagulation. Examination revealed a faint malar rash, cortical blindness and long tract neurological signs. Her ECG showed ischaemic changes and the admission troponin was significantly raised (3773ng/L). An echocardiogram showed new left ventricular dysfunction and a subsequent cardiac MRI was in keeping with coronary artery disease. Investigations showed an acute kidney injury, newly deranged liver function tests and a raised INR (>11, with no bleeding). Complement was normal with a low dsDNA titre. Urinalysis revealed proteinuria and a protein creatinine ratio measured 176mg/mmol. MRI diffusion weighted brain imaging showed acute bilateral occipital and left fronto-parietal infarcts. She had symptoms of a lupus flare with arthralgia and a butterfly facial rash. COVID-19 PCR tests were negative and she had not been recently vaccinated. She was diagnosed with CAPS and transferred to St Thomas' hospital intensive care. On arrival, she received 1mg intravenous vitamin K followed by triple therapy for CAPS: an unfractionated heparin infusion, oral prednisolone 40mg daily, 5 days of plasma exchange and, given her background of SLE, she was treated with intravenous cyclophosphamide (according to the EUROLUPUS regimen). Intravenous methylprednisolone was avoided due to a previous hypertensive encephalopathy reaction. She responded rapidly. Her troponin fell from a peak of 5054 to 294ng/ L, her creatinine settled at a new baseline (232umol/L) and her liver function normalised. She was switched back to warfarin due to her metallic valve and started on aspirin for cardiovascular secondary prevention. She required physical and occupational therapy due to her strokes but recovered well. Case report - Discussion: According to the 2003 criteria, CAPS can be classified as definite when there is evidence of: -3 organs involved, development of manifestations simultaneously or within a week, confirmation by imaging and/or histopathology of small vessel occlusion and positive antiphospholipid antibodies. Probable CAPS is when 3 out of the 4 criteria are present. In this case, three organs were confirmed to be involved with imaging showing cerebral and cardiac ischaemia. Her creatinine rose from a base of 190 to 289umol/L coupled with a high protein creatinine ratio confirming renal involvement. A Budd-Chiari syndrome was also suspected due to deranged liver function tests and INR, though imaging performed after therapy did not confirm this. A biopsy of any of these four organs was not feasible given the severity of her presentation and coagulopathy. There are no randomised controlled trials but data from the CAPS registry guides treatment and management follows a logical approach: anticoagulation to treat thrombosis, glucocorticoids for inflammation and plasma exchange (or IVIG) to remove the circulating autoantibodies. Triple therapy was associated with a reduced mortality compared to no treatment (28.6% versus 75%, respectively). Following analyses from the CAPS registry we also chose to treat with cyclophosphamide, which is associated with improved survival in patients with SLE. This decision was based on the clinical features of an SLE flare as opposed to serological grounds. There have b en reports of rituximab and eculizumab being used successfully in CAPS, though generally as a last resort. As complement activation is seen in animal models of antiphospholipid syndrome thrombosis and rituximab is often used in refractory SLE, they may prove to be promising agents for refractory CAPS. Case report - Key learning points: 1. Prompt recognition and early treatment is vital in managing CAPS 2. Triple therapy with anticoagulation, glucocorticoids and plasma exchange / IVIG is associated with better survival in CAPS 3. Cyclophosphamide is associated with better survival in patients with CAPS and concomitant SLE.

A Series of Catastrophic Events

Case report - Introduction: Catastrophic antiphospholipid syndrome (CAPS) is a rare, life-threatening disease occurring in up to 1% of antiphospholipid syndrome (APS) cases. It was first defined in 1992 and remains a difficult to treat entity with a mortality rate of 37%. We describe a patient with systemic lupus erythematosus (SLE) and CAPS presenting with simultaneous multi-organ injuries who was successfully managed with 'triple' therapy including cyclophosphamide. Case report - Case description: A 42-year-old female presented to her local hospital with chest pain and worsening vision. She had a background of SLE, triple antibody-positive APS (previous DVT, pregnancy loss and strokes), hypertension, a metallic mitral valve, a previous myocardial infarction and pre-existing visual impairment due to a prior intra-cerebral bleed related to anticoagulation. Examination revealed a faint malar rash, cortical blindness and long tract neurological signs. Her ECG showed ischaemic changes and the admission troponin was significantly raised (3773ng/L). An echocardiogram showed new left ventricular dysfunction and a subsequent cardiac MRI was in keeping with coronary artery disease. Investigations showed an acute kidney injury, newly deranged liver function tests and a raised INR (>11, with no bleeding). Complement was normal with a low dsDNA titre. Urinalysis revealed proteinuria and a protein creatinine ratio measured 176mg/mmol. MRI diffusion weighted brain imaging showed acute bilateral occipital and left fronto-parietal infarcts. She had symptoms of a lupus flare with arthralgia and a butterfly facial rash. COVID-19 PCR tests were negative and she had not been recently vaccinated. She was diagnosed with CAPS and transferred to St Thomas' hospital intensive care. On arrival, she received 1mg intravenous vitamin K followed by triple therapy for CAPS: an unfractionated heparin infusion, oral prednisolone 40mg daily, 5 days of plasma exchange and, given her background of SLE, she was treated with intravenous cyclophosphamide (according to the EUROLUPUS regimen). Intravenous methylprednisolone was avoided due to a previous hypertensive encephalopathy reaction. She responded rapidly. Her troponin fell from a peak of 5054 to 294ng/ L, her creatinine settled at a new baseline (232umol/L) and her liver function normalised. She was switched back to warfarin due to her metallic valve and started on aspirin for cardiovascular secondary prevention. She required physical and occupational therapy due to her strokes but recovered well. Case report - Discussion: According to the 2003 criteria, CAPS can be classified as definite when there is evidence of: -3 organs involved, development of manifestations simultaneously or within a week, confirmation by imaging and/or histopathology of small vessel occlusion and positive antiphospholipid antibodies. Probable CAPS is when 3 out of the 4 criteria are present. In this case, three organs were confirmed to be involved with imaging showing cerebral and cardiac ischaemia. Her creatinine rose from a base of 190 to 289umol/L coupled with a high protein creatinine ratio confirming renal involvement. A Budd-Chiari syndrome was also suspected due to deranged liver function tests and INR, though imaging performed after therapy did not confirm this. A biopsy of any of these four organs was not feasible given the severity of her presentation and coagulopathy. There are no randomised controlled trials but data from the CAPS registry guides treatment and management follows a logical approach: anticoagulation to treat thrombosis, glucocorticoids for inflammation and plasma exchange (or IVIG) to remove the circulating autoantibodies. Triple therapy was associated with a reduced mortality compared to no treatment (28.6% versus 75%, respectively). Following analyses from the CAPS registry we also chose to treat with cyclophosphamide, which is associated with improved survival in patients with SLE. This decision was based on the clinical features of an SLE flare as opposed to serological grounds. There have b en reports of rituximab and eculizumab being used successfully in CAPS, though generally as a last resort. As complement activation is seen in animal models of antiphospholipid syndrome thrombosis and rituximab is often used in refractory SLE, they may prove to be promising agents for refractory CAPS. Case report - Key learning points: 1. Prompt recognition and early treatment is vital in managing CAPS 2. Triple therapy with anticoagulation, glucocorticoids and plasma exchange / IVIG is associated with better survival in CAPS 3. Cyclophosphamide is associated with better survival in patients with CAPS and concomitant SLE.

Imaging of COVID-19 vasculopathy from head to toe: Egyptian collective experience after 2 years of the pandemic

Background: COVID-19 vasculopathy is a critical condition that impacts the disease prognosis including vasculitis and thromboembolic complications. This study aimed to provide the Egyptian experience about the COVID-19 vasculopathy during the past two years of the pandemic and to collectively include the different modalities and imaging techniques for the diagnosis of cerebrovascular, pulmonary, gastrointestinal, and peripheral arterial vascular complications. Result(s): This is a multi-center retrospective analysis of 3500 PCR-proved COVID-19 infection between March 2020 and December 2021. A cohort of 282 consecutive patients with COVID-19 vasculopathy was considered for inclusion. They included 204 males and 78 females (72:28%). The mean age was 68 years, and age ranged from 48 to 90 years. Five radiologists evaluated the different imaging examinations in consensus including computed tomography (CT), CT-angiography (CTA), CT-perfusion (CTP), magnetic resonance imaging (MRI), MR-arteriography (MRA), and MR-venography (MRV). 244/282 (86.5%) patients suffered from non-hemorrhagic cerebral ischemic infarctions. 13/282 (4.6%) patients suffered from hemorrhagic cerebral infarctions. 5/282 (1.8%) patients suffered from cerebral vasculitis. Pulmonary vascular angiopathy was detected in 10/282 (3.5%) patients, including pulmonary embolism in 10/10 patients, pulmonary infarctions in 8/10 patients, pulmonary vascular enlargement in 5/10 patients, and vascular "tree-in-bud" sign in 2/10 patients. Intestinal ischemia and small bowel obstruction were detected in 3/282 patients (1%) while GIT bleeding was encountered in 4/282 patients (1.4%). Lower limb arterial ischemia was found in 3/282 patients (1%). Additionally;39/282 (13.8%) patients developed peripheral deep venous thrombosis (DVT) due to prolonged ICU recumbence while 28/282 (10%) patients developed jugular vein thrombosis sequel to prolonged catheterization. A p value (0.002) and (r) = 0.8 statistically proved strong significant relation between COVID-19 vasculopathy and D-dimer levels. Conclusion(s): Multi-system vasculopathy was a serious complication of COVID-19 which impacted the patients' morbidity and mortality. An Egyptian experience about the COVID-19 vasculopathy during the past two years of the pandemic was provided. It encountered the different modalities and imaging techniques for the diagnosis of cerebrovascular, pulmonary, gastrointestinal, and peripheral arterial COVID-19 vascular complications. Copyright © 2022, The Author(s).

Cerebral Vasculopathy-Associated Ischemic Stroke in the Setting of Bacterial Meningitis

INTRODUCTION: Bacterial Meningitis is known to have high morbidity and mortality rates. A less recognized complication from this disease includes acute ischemic stroke, which conveys a worse prognosis. DESCRIPTION: A 37-year-old previously healthy woman presented to the hospital with progressive encephalopathy associated with ataxia and dysarthria. Her immediate past travel history revealed a trip to Europe where she endured a COVID19 infection three weeks before her admission. Nevertheless, she recovered without any complications. However, she developed fatigue and headaches, prompting a diagnosis of post-COVID19 syndrome by her primary care physician. Over the course of several days, her ability to carry out her normal daily activities and perform work-related duties deteriorated as she developed severe fatigue accompanied by a painless diffuse skin rash. She presented to the ED once she started having symptoms of dysarthria, abasia, and truncal ataxia. An emergently obtained CSF sample was consistent with bacterial meningitis. Standard empiric antibiotics and steroids were administered. The patient's condition acutely decompensated soon after antibiotics administration. A follow-up head CT showed global cerebral edema and hydrocephalus, triggering an EVD placement for ICP monitoring. An MRI brain showed multiple bilateral acute ischemic strokes in the brainstem and basal ganglia. A head CT angiography showed diffuse narrowing of the cerebral arteries. The patient ultimately completed a course of antibiotics (Neisseria PCR was positive). We used TCD-guided blood pressure augmentation to prevent the progression of cerebral ischemia. The patient was discharged on long-term steroid therapy for presumed post-infectious vasculopathy. A follow-up MRI brain did not reveal a progression of cerebral ischemia. DISCUSSION: Bacterial Meningitis is a severe disease with significant complications. One such complication is ischemic stroke. However, the exact pathophysiology is unknown. Understanding the risks of developing cerebral ischemia and the related pathophysiology could help improve patient outcomes with better treatment modalities. The interplay between COVID19 infection and conventional infectious pathogens is an ongoing area of interest.

Efficacy and Safety of Standardized Protocol of CPAP Therapy for Full-Term Newborns in Delivery Room at Transient Tachypnea: Clinical Trial with Historical Control

Background. Nowadays there is no consensus on the tactics and optimal protocol for Continuous Positive Airway Pressure (SPAP) at transient tachypnea of newborns (TTN) in delivery room. Objective. The aim of the study is to examine the efficacy and safety of standardized protocol of CPAP therapy for newborns with TTN in delivery room. Methods. The clinical study (implementation of standardized CPAP protocol) included full-term infants (gestational age - 37-41 weeks) with diagnosed TTN and CPAP therapy during first 60 minutes of life. Similar inclusion criteria were applied for the historical control group (born within previous year for whom CPAP was implemented according to "usual" protocol). Initiation of mononasal CPAP in main group was carried out when respiratory disorders were assessed according to Downes scale >= 3 points with control points at 20-40-60 minutes via the same scale, in control group at >= 4 points - for all cases, and according to the doctor's decision at 1-3 points. Mean airway pressure was maintained at 8 and 5-10 cm H2O, CPAP duration was 20-60 and 5-30 min, respectively. The major endpoints: the frequency of patient transfer from delivery room to intensive care unit or hospitalization to the neonatal pathology department, as well as total period of hospitalization. Moreover, frequency of invasive manipulations (intravenous catheterization, parenteral feeding), antibacterial therapy, cerebral injuries (cerebral ischemia, intracerebral hemorrhage), nasal passages injuries, pneumothorax (in the first 24 hours of life) were recorded during the entire hospitalization period. Results. 140 newborns with TTN were included in the clinical study, 30 were excluded from the study, specifically 13 due to violation of the CPAP protocol. The historical control group included 165 newborns. This groups were comparable for most baseline (before the start of CPAP) indicators except for maternal COVID-19 frequency during pregnancy and twin newborns frequency. This groups were comparable for most baseline (before the start of CPAP) indicators except for the frequency of maternal COVID-19 cases during pregnancy and the frequency of twin newborns. Hospitalization rate in intensive care units (18.2 versus 70.3%;p < 0.001) and neonatal pathology departments (31.8 versus 80.0%;p < 0.001), as well as total period of hospitalization (3 versus 10 days;p < 0.001) were lower in the standardized CPAP therapy group. Lower frequency of invasive manipulations, antibacterial therapy, and cerebral ischemia was recorded in this group. The safety of SPAP administration in delivery room was confirmed by the absence of nasal passages injuries in both groups, as well as comparable frequency of pneumothorax. Conclusion. The use of standardized CPAP protocol in delivery room for full-term newborns with TTN had higher rate of favorable hospitalization outcomes. Study limitations require validation of all the findings in independent studies. Copyright © 2022 Publishing House of the Union of Pediatricians. All rights reserved.

Cerebrovascular accident in a child with precursor B-cell acute lymphoblastic leukemia and coronavirus disease 2019: a case report.

BACKGROUND: Coronavirus disease 2019 can lead to rare but severe and life-threatening diseases in susceptible high-risk populations, including patients with immunodeficiency. A rare event in this report is stroke following COVID-19 disease in a patient with an immunocompromised background due to leukemia and anti-cancer treatments. CASE PRESENTATION: A 6-year-old iranian girl with precursor B-cell leukemia receiving vincristine therapy presented with fever and absolute neutrophil count < 500. Her severe acute respiratory syndrome coronavirus 2 polymerase chain reaction test was positive. During hospitalization, she had abrupt onset tachypnea, reduced O2 saturation, and generalized tonic-clonic seizures treated with phenytoin and levetiracetam. Right parietal lobe ischemia was found on a brain computed tomography scan, and the cerebrospinal fluid polymerase chain reaction test was positive for severe acute respiratory syndrome coronavirus 2. Several days later, she developed lower extremity paralysis and speech impairment, so speech therapy and physiotherapy were initiated. The patient also received dexamethasone, mannitol, heparin, and remdesivir. She was discharged with enoxaparin and levetiracetam. Chemotherapy resumed 2 weeks following discharge. Her speech and walking improved after 10 months of follow-up, and bone marrow aspiration showed total remission. CONCLUSION: Owing to the link between coronavirus disease 2019 and hematologic cancers with hypercoagulopathy and the tendency of patients with leukemia to have coronavirus disease 2019 complications, children with leukemia as well as suspected coronavirus disease 2019 must be hospitalized to prevent blood clot formation.

Ischemic stroke in a pediatric patient: complication of the course of CoVid-19 (clinical case and literature review)

Recently, there is a growing number of publications about the complicated course of the COVID-19 in children. The literature describes only a few cases of acute cerebrovascular diseases. In the case described in this paper, an 11-year-old boy presented with COVID-19 complicated by an ischemic stroke. Moderate ischemic stroke (pedNIHSS 14 points) occurred on the 7th day after infection with the SARS-CoV-2 and the background of the multisystem inflammatory syndrome. It has started with the left hemiplegia, hemianesthesia, central-type facial moderate palsy, and pseudobulbar palsy. Focal brain ischemia in the right hemisphere brain and occlusion of the right middle cerebral artery was confirmed by neuroimaging data. The treatment observed regression of neurological symptoms: there were minimal movements in his left arm and leg, facial muscles, also improved gulping and speech. After 1.5 months, the stroke was provided clinical examination: no markers predisposing to hypercoagulability or a prothrombotic state, as well as markers of systemic diseases. According to neuroimaging data, was occurred recanalization of occluded middle cerebral artery, was post-ischemic changes. This case shows the possibility of stroke against the background of COVID-19 in children without somatic problems and makes the doctor more vigilant during the treatment of COVID-19. Copyright © 2022 ABV-Press Publishing House. All rights reserved.

New clinical development of RGTA based Matrix therapy technology in regenerative medicine

Background: Matrix therapy is a newly coined name emphasizing the importance of the extracellular matrix in regenerative medicine. Heparan sulfates (HS) are key elements of the extracellular matrix (ECM) scaffold which store and protect most growth factors/ cytokines controlling the cell migration and differentiation required for healing processes. We have engineered biodegradable nanopolymers (alpha 1-6 polyglucose carboxymethyl sulfate) mimicking (RGTA) to replace destroyed HS in the damaged ECM scaffolding and to protect cytokines produced by healthy neighboring cells, thereby restoring the ECM microenvironment and tissue homeostasis and, if needed, provide a homing niche for cell therapy. This matrix therapy approach has considerably improved the quality of healing in various animal tissue injury models including skin, cornea, digestive mucosa, muscle lung and brain tissues showing tissue protection with reduction or absence of fibrosis resulting in a regeneration process. Due to the ubiquity of HS, numerous clinical developments have been identified and over 200 000 patients have been treated in the last 10 years for skin and corneal wounds with dedicated products based on this technology. Material(s) and Method(s): RGTA OTR4120 and 4132 have been designed to optimize binding and protection of several chemokines and growth factors, are produced in GMP facilities and fulfill all preclinical requirements for quality, safety and pharmacological data for human clinical trials. Result(s): In this short presentation we shall describe some preclinical data supporting brain ischemia protection, lung fibrosis and skin scar reduction, as well as clinical data on going trials aiming at reducing stroke sequala (safety phase 1/2*), pilot study on 13 patients with Covid (showing safety and efficacy on reduction of fibrosis, time to recovery from dyspnoea and fatigue* *). Skin scar reduction studies and submitted RCT proposal. Conclusion(s): Matrix therapy using the RGTA strategy has taken time before optimizing molecules and dosages but is now mature for a wide variety of developments and treatments. In all the cases safety was assessed and efficacy needed to be supported by RCT which are now in progress.

Infantile ischemic stroke secondary to profound arteriopathy.

Pediatric arterial ischemic stroke (AIS) is an uncommon emergency department (ED) presentation. We share the case of a 4-month-old female with a chief complaint of irritability and difficulty feeding. During ED evaluation, she developed lateral gaze deviation, tongue deviation, and rhythmic leg movements. Computed tomography of the head revealed a right-sided hypodensity concerning for ischemic infarct without hemorrhagic conversion. Subsequent brain magnetic resonance imaging and arteriography confirmed a large right-sided cerebral infarct and demonstrated narrowing and tortuosity of almost all extra- and intracranial vessels. Comprehensive pediatric AIS workup, including echocardiogram and laboratory tests for anemia, hypercoagulability, inflammatory, and genetic panels, were non-diagnostic. This case highlights the difficulty in diagnosis of pediatric AIS due to low clinical suspicion, limited neurologic examination, and non-specific presentations that may suggest stroke mimics. Maintenance of clinical suspicion and early recognition of pediatric AIS can result in earlier initiation of neuroprotective measures and optimization of imaging strategies for better outcomes.

Introduction

Introducing Information Technology (IT) tools in today’s and future medicine is being increasingly considered all over the world, especially in developed countries. Indeed, these countries are suffering the most from population aging and chronic diseases. This induces original challenges not only for healthcare but also for wellbeing. In this sense, Predictive, Preventive and Personalised Medicine (3PM) has been identified since more than a decade as a research avenue having huge potential for developed societies. © Springer Nature Switzerland AG 2020.

CEREBROVASCULAR DISEASES IN PATIENTS WITH SARS-COV-2 INFECTION: A NATIONAL SERIES

Background and aims: There is a higher incidence of cerebrovascular disease (CVD) in patients with SARS-CoV-2 infection. We aim to describe a national series of CVD in patients with confirmed SARS-CoV-2 infection. Methods: Fourteen Brazilian Stroke Centers registered clinical, neuroimaging and laboratory findings from April to November 2020. Results: We included 344 patients in the final analysis. Age ranged from 20-95 (median 57[57, 75] years). Cerebral ischemia (CI) occurred in 83.7%(n=288), intraparenchymal hemorrhage (IPH) 6.7%(n=23), central venous thrombosis (CVT) 5.2%(n=18) and subarachnoid hemorrhage (SAH) 4.4% (n=15). CVD was the first symptom of SARS-CoV-2 in 37.8% of cases - among those with SAH, 60% had no systemic symptoms. CI cases had higher values of Dimer-D compared to others. Involvement of at least two arterial territories occurred in 13.8%. Among IPH patients, 25% were under anticoagulation with heparin. Patients with SAH had a spontaneous etiology in 35.7%. Dimer-D levels at admission were associated with worse outcomes (mRS3-6) (OR1.14, 95%CI1.008-1.29, p=0.03), in an adjusted analysis. The time of onset of neurological symptoms (TONS) since SARS-CoV-2 infection was indirectly related to neurological severity at admission (-0.17, p=0.04,). In-hospital treatment with corticosteroids was associated with in-hospital encephalopathy (OR2.5,95%CI 1.01-6.16,p=0.04). Poor outcome (mRS3-5) occurred in 54.1% of cases. Conclusions: Patients with CVD and SARS-CoV-2 are at higher risk of unfavorable outcomes. The TONS since infection is related to neurologic severity;and serum Dimer-D levels may be useful for prognostication. The higher prevalence of non-aneurysmal SAH cases suggests pathophysiological mechanisms other than a hypercoagulable state.

Cerebrovascular injury associated with COVID-19 and non-COVID-19 acute respiratory distress syndrome

Background: Neurologic complications of Coronavirus Disease 2019 (COVID-19) may be associated with neurotropism of the virus or secondary brain injury from systemic inflammation. Acute respiratory distress syndrome (ARDS) is associated with cerebrovascular injury, including both ischemia and hemorrhage. We aimed to compare brain MRI findings of COVID-19 associated ARDS with non-COVID-19 ARDS. Methods: A registry of patients with COVID-19 from March 2020 through July 2021 from a hospital network was reviewed. Patients who met criteria for ARDS by Berlin definition and underwent MRI during their hospitalization were included. These patients were matched 1:1 by age and sex with patients who underwent MRI from another registry of patients of ARDS in the same hospital between 2010 and 2018. Cerebrovascular injury was classified as either acute cerebral ischemia (ischemic infarct or hypoxic ischemic brain injury) or intracranial hemorrhage (ICH) including intraparenchymal hemorrhage, subarachnoid hemorrhage, subdural hematoma, and cerebral microbleeds (CMBs). Results: Of 13,319 patients with COVID-19 infection, 26 patients had ARDS and MRI. Sixty-six of 678 non-COVID-19 ARDS patients had an MRI and were matched 1:1 by age and sex resulting in 23 matched pairs. The median age was 66 and 59% of patients were male. Patients with COVID-19 ARDS were more likely to have hypertension and chronic kidney disease but otherwise baseline medical characteristics were similar. ARDS severity as determined by PaO2/FiO2 ratio at ICU admission was similar between both groups. No difference was seen in the prevalence of cerebrovascular injury (52% vs 61%, p=0.8), cerebral ischemia (35% vs 43%, p=0.8), ICH (43% vs 48%, p=1.0), or CMBs (43% vs 39% p=1.0) on MRI between the COVID-19 and non-COVID-19 cohorts. However, two unique patterns of injury were seen only among COVID-19 patients: hemorrhagic leukoencephalitis (3 patients, 12%) and bilateral cerebral peduncular ischemia with microhemorrhage (2 patients, 8%). Conclusion: Cerebrovascular injury was common in both COVID-19 and non-COVID-19 ARDS without significant frequency difference. However, COVID-19 ARDS had unique neuroimaging patterns that may indicate distinct patterns of brain injury of COVID-19.

Thrombotic Sequela of Asymptomatic COVID-19 Infection.

Severe coronavirus disease 2019 (COVID-19) is known to be associated with thrombotic events like ischemic stroke. However, in the case of mild or asymptomatic disease, a thrombotic event like ischemic stroke is rare and has never been reported in our country. We present the case of a 28-year-old male patient with no co-morbidities who was diagnosed to have ischemic stroke involving the basilar artery. No risk factors for ischemic stroke could be found except for post-COVID-19 status, evident by the presence of antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

A severe case of bilateral COVID-19 pneumonia with concurrent ischemic stroke and myocardial infarction

Looking at the recent data provided in literature, we can see an association between cardiovascular and cerebrovascular accidents in COVID-19 thought to be related to severe inflammation and prothrombotic environment caused by the virus. This article reports a patient presenting with typical signs and symptoms of SARS-CoV-2 infection including flu like symptoms and respiratory distress. Initially a chest CT was performed that showed characteristic findings of atypical pneumonia caused by SARS-CoV-2 virus which was later confirmed with a nasopharyngeal PCR positive for COVID-19. During the course of admission patient developed unstable angina. Further testing confirmed an acute ST elevation myocardial infarction. While on anticoagulant treatment, patient showed signs of cerebrovascular accident. An emergency brain CT was ordered which did not yield any significant changes supporting our clinical diagnosis. Further diagnostic workup using magnetic resonance imaging disclosed evidence of cerebral ischemia in medial cerebral artery territory. Our study suggests that prophylactic anticoagulant regiment is not reassuring in COVID-19 patients and close observation and vigilance, can help clinicians to act timely and can improve patient survival.

Diagnostic and Therapeutic Challenges of Cerebral Venous Thrombosis in SARS-CoV-2 Infection: A Case Report and Review of Literature.

Headache, a common prodromal symptom of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, can also be a manifestation of cerebral venous thrombosis (CVT), secondary to COVID-19. CVT management continues to evolve, with direct oral anticoagulants (DOACs) emerging as an alternative to warfarin. A 44-year-old Asian female, with no past medical history, presented to the emergency room (ER) with complaints of nonproductive cough and left-sided headache. She denied a history of COVID-19 vaccination, and SARS-CoV-2 testing (with reverse transcriptase-polymerase chain reaction) was positive. Non-contrast computed tomography (CT) of the head revealed left transverse sinus hyperdensity, consistent with dense vein sign, and magnetic resonance venography (MRV) confirmed the presence of thrombus. The initial treatment included subcutaneous enoxaparin with headache resolution, and she was discharged on apixaban. Five weeks later, a non-contrast head CT showed resolution of the dense vein sign and recanalisation of left transverse sinus was seen on MRV. This report has highlighted the need for increased awareness of coagulopathy and thrombotic events, including cerebral venous thrombosis, in patients infected with SARS-CoV-2. Unremitting headache, in context of SARS-CoV-2 infection, should be evaluated with appropriate neurovascular imaging. Controlled studies are required to compare the safety and efficacy of DOACs with warfarin for management of cerebral venous thrombosis.