Bilateral Cerebral Strokes and Adrenal Hemorrhage Associated with Mis-A

INTRODUCTION: Multisystem Inflammatory Syndrome in Adults (MIS-A) is an underrecognized post-infectious manifestation of COVID-19.We report a case of a 21-year-old male with MIS-A who presented with adrenal hemorrhages, acute kidney injury (AKI) and cerebral strokes leading to multiorgan system failure and death. DESCRIPTION: A 21-year-old, morbidly obese male presented at an outside hospital with COVID-19 and abdominal pain. His abdominal CT demonstrated bilateral adrenal hemorrhages, he was discharged home on hydrocortisone. A month later was readmitted with fever, diarrhea, thrombocytopenia and AKI. Laboratory work revealed creatinine 5.49mg/dL, ferritin 701ng/ml, BNP 3020 pg/ml and D-Dimer 17,650 ng/ml. He received hydrocortisone, intravenous immunoglobulin and enoxaparin. Fever subsided and renal function normalized. On day 7 he developed acute altered mental status and recurrent AKI. Head CTA showed multiple short stenotic segments in the anterior circulation, diminutive appearance of several intracranial arteries and basal ganglia hypodensities. Brain MRA demonstrated extensive bilateral acute/subacute strokes, no evidence of sinus thrombosis and markedly decreased caliber of internal carotid, left middle and anterior cerebral arteries without evidence of thrombus. He received aggressive neurocritical care management including decompressive craniectomy and pulse steroids for suspected vasculitis. Due to the severity of his neurological injury and poor neurologic prognosis family elected to withdraw support. His autopsy demonstrated hepatomegaly, acute tubular necrosis, bilateral adrenal hemorrhages and hypercellular bone marrow with myeloid predominance. Neuropathology showed severe segmental stenosis of the carotid arteries and bilateral vertebral arteries. DISCUSSION: Stroke is a potentially life-threatening complication of COVID-19 including large vessel occlusion and less frequently vasculitis-like phenotype with vessel wall enhancement. Despite initial improvement, our patient developed an acute extensive ischemic stroke leading to a devastating neurologic injury. The neuropathology findings suggest SARS-CoV-2 associated vasculitis. Stroke in the context of COVID-19 may have different pathogenetic mechanisms, clinical characteristics and complications that warrant further investigation.

IDIOPATHIC TROPONEMIA AFTER TRANSCAROTID ARTERY REVASCULARIZATION

SESSION TITLE: Etiologies of Cardiovascular Disease Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Troponin level (Tnl) is usually used as confirmation of acute myocardial infarction (AMI) and is a sensitive marker. It is usually increased within 2-3 hours after AMI. In most cases, increased in Tnl is associated with symptomatic chest pain, cardiac ischemia, chronic coronary syndromes, etc. It can also be elevated in other conditions without cardiac injuries, like critical illness: COVID infection, septic shock, acute stroke and burns. CASE PRESENTATION: A 72 y/o man with history of b/l internal carotid artery (ICA) stenosis (70% in R-ICA and 80-90% in L-ICA) underwent elective left trans-carotid artery revascularization (TCAR). He was transferred to ICU after an uneventful procedure, for monitoring. His history was significant for HTN, HLD, Meniere's disease, gout, prior CVA of L-frontal lacunar and R-PICA (posterior inferior cerebellar artery). Postop vitals: BP 114/60 mmHg, HR 65, RR 16, O2 sat 98%. Tnl increased to 1.95 and then declined (normal 0 - 0.4 ng/ml). He was AAOx4, and asymptomatic. Post-op serial EKGs: normal sinus rhythm with no ST/T wave changes. Echo: EF 60%, normal biventricular size and function. LDL <70, A1C 5.9, normal TSH, no CPK elevation. Other labs: normal, No new neurological deficits. He was continued on ASA, clopidogrel, metoprolol, amlodipine and lisinopril. His hospital stay was uneventful, and he was discharged on post-op day 3. DISCUSSION: Cardiac troponin complex has its distinct subunits according to their functions: highly conserved Ca2+ binding subunit (cTnC);actomyosin ATPase inhibitory subunit and tropomyosin binding subunit. They play the pivotal role in regulating myocardial muscle contraction and relaxation and demonstrate as sensitive biomarkers for the myocardial injuries. Interestingly, there are many other causes that lead to increased cardiac troponin level without remarkable myocardial injuries or ischemia. Elevated Tnl after TCAR procedure can also be due to its surgical complication of a chance of hypoperfusion during the procedure. Our patient's surgery was uneventful. In one randomized controlled trial, it is stated that the risk of having CVA and AMI is higher in carotid endarterectomy compared to revascularization in patients with carotid artery stenosis. Our patient did not have any post-op complication, and only had an idiopathic elevation of troponin. CONCLUSIONS: The role of Tnl plays an important role in confirmation of myocardial infarction or ischemia but it can be idiopathic. Unpublished data from our institution revealed no increase in troponin s/p TCAR after uneventful procedures. This is the first reported case presenting with elevated troponin level without any pertinent positive findings (EKG changes/symptoms). Maybe in uneventful TCAR procedure troponin should not be ordered? Reference #1: Defilippi, C.R., Tocchi, M., Parmar, R.J., Rosanio, S., Abreo, G., Potter, M.A., Runge, M.S., & Uretsky, B.F. (2000). Cardiac troponin T in chest pain unit patients without ischemic electrocardiographic changes: angiographic correlates and long-term clinical outcomes. Journal of the American College of Cardiology, 35 7, 1827-34. Reference #2: Gordon AM, Homsher E, Regnier M. Regulation of contraction in striated muscle. Physiol Rev. 2000 Apr;80(2):853-924. doi: 10.1152/physrev.2000.80.2.853. PMID: 10747208. Reference #3: Brott, T.G., Hobson, R.W., Howard, G., Roubin, G.S., Clark, W.M., Brooks, W., Mackey, A., Hill, M.D., Leimgruber, P.P., Sheffet, A.J., Howard, V.J., Moore, W.S., Voeks, J., Hopkins, L.N., Cutlip, D.E., Cohen, D.J., Popma, J.J., Ferguson, R.D., Cohen, S.N., Blackshear, J.L., Silver, F.L., Mohr, J.P., Lal, B.K., & Meschia, J.F. (2010). Stenting versus endarterectomy for treatment of carotid-artery stenosis. The New England journal of medicine, 363 1, 11-23. DISCLOSURES: No relevant relationships by Moses Bachan No relevant relationships by Zin Min Htet No relevant relationships by Z nobia Khan No relevant relationships by Zin Oo

Carotid Endarterectomy Pathway at a Hub Site - the Impact of COVID-19

Aim: NICE Guidelines recommend that all patients who suffer from a TIA or non-disabling stroke are rapidly assessed and imaged. Patients suspected of having symptomatic carotid stenosis should be referred to a Vascular Centre for consideration of urgent carotid endarterectomy (CEA) within two weeks. Our aim was to assess the current referral-to-treatment timeline for carotid surgery in our Vascular Centre against these standards and explore the impact of the COVID-19 Pandemic on this. Method: We retrospectively interrogated the National Vascular Registry to identify patients undergoing CEA “pre-pandemic” (Jan - Dec 2019) and in a “contemporary period” (Jan - Sept 2021) Results: A total of 129 patients underwent CEA in the defined periods, including pre-Pandemic (80 patients) and contemporary (49 patients) periods. One patient had to be excluded due to inability to identify date of first symptoms. 2019 Data: The times (median) from symptoms to surgery were 10 days (interquartile range (IQR) 23 days), from imaging-to-referral, one day and from vascular review to surgery, two days. 2021 Data: The times (median) from symptoms to surgery were 10 days (IQR 12 days), from imaging-to-referral, two days and from vascular review to surgery, one day. Conclusions: The median time from symptoms to surgery has remained the same from pre-Pandemic data, though there is a decrease in IQR in current practice. We recommend creating a CEA Pathway to optimise the carotid service.

Impact of COVID-19 on Patients Undergoing Scheduled Carotid Interventions

Objectives: The COVID-19 pandemic has drastically altered the medical landscape. Not in our lifetime have we seen such a rapid and widespread cancellation of scheduled vascular surgical operations. The objective of this study was to evaluate the impact of COVID-19 on the care of patients with carotid disease. Methods: An interim data analysis of the Carotid module of VASCC Project 1: Impact of COVID-19 on Scheduled Vascular Operations was performed. The Vascular Surgery COVID-19 Collaborative (VASCC) was founded in March of 2020. Modules were developed by international vascular surgeon working groups and extensively beta tested before implementation. Each participating site agreed to share a collection of patient data whose vascular surgeries were postponed due to the COVID-19 pandemic. The REDCap database, housed at the University of Colorado, was determined to be exempt from Institutional Review Board review. A total of 57 patients with carotid stenosis whose surgeries were postponed during the COVID-19 pandemic surge in the USA were included in the interim data analysis. Patients whose surgeries were scheduled but not postponed were not included. Results: The mean ± SD age of the 57 patients was 70.5 ± 10.8 years. Seventy per cent were male and 28.1% were female. Seventy-two per cent of patients were white, 17.5% were Hispanic, 1.8% were Asian or Pacific Islander, and 1.8% were black. Seventy-five per cent of patients were asymptomatic, 8.8% had a cerebrovascular accident (CVA), 8.8% had a transient ischaemic attack (TIA), 3.5% had amaurosis fugax, and no patients presented with crescendo TIA (Table 1). The average length of surgical delay was 78.3 ± 36.1 days, with a median of 73 days (interquartile range 45.75 days) (Table 2). Of the 57 patients, 33 (57.9%) had surgeries postponed and successfully completed surgery at time of data entry. Seventy-two per cent of the postponement were due to intuitional policy (Table 3). No patients (0%) decompensated or required an emergency surgery during the delay. Two patients (4.0%) with carotid disease died while waiting for surgery. The cause of death of both patients was unrelated to cerebrovascular disease. Conclusions: None of the asymptomatic patients became symptomatic during the surgery delay. Two patients with carotid disease died while waiting for surgery due to causes not related to cerebrovascular disease. Our interim analysis supports institutional and national guidelines in the USA that patients with asymptomatic carotid stenosis may be safely postponed during a COVID-19 pandemic surge. Further data are needed to evaluate the impact of patients with symptomatic carotid stenosis. [Formula presented] [Formula presented] [Formula presented] [Formula presented] [Formula presented] [Formula presented]

LOOKING BACK, BEFORE LOOKING FORWARD. FIVE YEARS DATA FROM RES-Q REGISTRY IN ROMANIA

Background and aims: RES-Q Registry is the first stroke database in Romania. The aim is to map key performance indicators for quality of stroke care and to improve stroke management Methods: Each center registers all stroke patients hospitalized in march, yearly. Results: The number of participated centers has increased from 10 in 2017 to 36 in 2021. In five years we have registered 8467 patients. The median age was 71.46 years, median NIHSS at admittance 7.8 points, 82.8% ischemic strokes. Despite improvement in revascularization procedures (intravenous thrombolysis increased from 2.27% in 2017 to 10.56 in 2021, and mechanical thrombectomy from 0,1% to 1,7%) median Modified Rankin Score at discharge did not change significantly and mortality has increased (from 15.09% in 2017 to 19.03% in 2021). A reason for increased mortality is due to Covid-19 pandemic (poor access to primary care, more severely ill, increased door to needle time due to epidemiologic circuits), but beside this, there are unsolved problems, such as the very low percentage (below 1%) of decompressive hemicraniectomy, the reduced capacity to actively detect atrial fibrillation ( 36.9% of patients are still screened for AF only by repeated ECG), the low percentage of carotid imaging (56.7%) and revascularization procedures (less than 7% of symptomatic carotid stenosis). Conclusion: For a better prognosis of stroke we need to increase the number of properly financed stroke units, the educational activities, and to elaborate and implement a national stroke plan.

Endovascular Reperfusion of Acute Large Vessel Occlusion Stroke

Acute stroke treatment continues to evolve with optimization of systemic intravenous thrombolysis and endovascular mechanical thrombectomy (MT) for intracranial large vessel occlusion (LVO). Neurointerventional techniques to achieve reperfusion in acute LVO stroke initially involved local intra-arterial infusion of thrombolytic agents. The subsequent development of MT devices has resulted in more complete and faster arterial recanalization while maintaining patient safety. Today, MT is standard of care for LVO stroke up to 24 h from last known well. In this chapter, we discuss various endovascular recanalization techniques for LVO stroke with illustrative cases.

Multiple strokes as complications of SARS-CoV-2 interstitial pneumonia

Background: SARS-CoV-2 infection is a respiratory pandemic illness whose linking with thromboembolic complications has been underlined. Sometimes, stroke can be a complication in CoViD- 19 patients. Description of the case: A 62-year-old male came to our attention after a week of asthenia, fever, nausea, dry cough;no cardiovascular risk factors nor other diseases were reported in his clinical history. An RT-PCR test for SARS-CoV-2 was positive. A chest X-Ray showed bilateral pneumonia with widespread interstitial involvement. He was immediately treated with dexamethasone, low molecular weight heparin and oxygen therapy. Because of desaturation (pO2 38.2 mmHg) non-invasive ventilation - CPAP was started, associated to prone positioning. After two days of initial good response with NIV, the patient was found unresponsive with respiratory acidosis (pH 7.25, pCO2 69 mmHg). He was then intubated and centralised to the Intensive Care Unit;there, trying to extubate the patient because of the respiratory improvement, he was still unresponsive. A brain CT scan found multiple supra and subtentorial strokes, even involving the encephalic trunk, with secondary hydrocephalus. An epiaortic CT angio scan showed occlusion of carotid siphons, vertebral arteries and Willis' polygon. The patient, unresponsive with mydriasis and areflexic, tetraplegic, was diagnosed with cerebral death. Conclusions: Thromboembolic complications in SARS-CoV-2 interstitial pneumonia, even in patients without comorbidities or cardiovascular risk factors, can result as strokes with high morbidity and mortality.