Cerebral microembolism during atrial fibrillation ablation can result from the technical aspects and mostly does not cause permanent neurological deficit.

INTRODUCTION: Atrial fibrillation ablation can be associated with microembolism detected in the intracranial arteries and risk of neurological incidents. The aims of this study were to evaluate microembolic signals (MES) during pulmonary vein isolation (PVI) and establish the potential significance of MES for damage of the brain in radiological investigation and neurological state. MATERIAL AND METHODS: In the prospective study we included patients with atrial fibrillation undergoing percutaneous pulmonary vein isolation (radiofrequency ablation/balloon cryoablation) with ultrasound monitoring of microembolisms in the middle cerebral artery. Neurological examination and MRI of the head were performed in all participants. RESULTS: The study enrolled 80 patients at a mean age of 58 years. Microembolisms during the monitoring of the flow in the right middle cerebral artery were recorded in 61 (76.3%) patients in the amount of 51-489 (mean: 239). Most often the microembolic signals were registered during the trans-septal puncture and the stage of ablation. In 89%, microembolisms were gaseous. Mean score on the Fazekas scale for the whole group before ablation: 0.87 ±0.7 (0-3, med. 1); after: 0.93 ±0.71. In 3 (4.3%) patients the lesions worsened during the follow-up period. None of the patients revealed a cardiovascular event during the follow-up period and no changes were observed in the neurological status. CONCLUSIONS: The majority of cerebral microembolisms generated during PVI are gaseous in nature. The cerebral microembolisms associated with PVI probably result from the technical aspects of the procedure and do not cause either permanent brain damage in the radiological investigation or neurological deficit.

Prevalence of atherosclerotic stenosis of the carotid and cerebral arteries in patients with stable or unstable coronary artery disease.

INTRODUCTION: Carotid artery atherosclerosis is a recognized predictor of cardiovascular events. The coexistence of coronary atherosclerosis and cerebrovascular disease is associated with unfavorable clinical outcomes. OBJECTIVES: The aim of this study was to determine the prevalence of hemodynamically and clinically significant carotid and / or cerebral artery stenosis in patients with stable and unstable coronary artery disease (CAD). PATIENTS AND METHODS: Cardiac and neurological examinations together with coronary angiography and carotid ultrasound were performed in 241 patients, and transcranial Doppler imaging of cerebral arteries in 114. The prevalence of hemodynamically significant internal carotid artery (ICA) stenosis, intracranial artery stenosis, and clinical signs of central nervous system ischemia were compared between patients with stable and unstable CAD. RESULTS: There was no significant difference in the prevalence of ICA stenosis (15.3% vs 19%) and intracranial artery stenosis (18% vs 16%) between patients with stable and unstable CAD. Risk factors for cerebral artery stenosis included ICA stenosis (odds ratio [OR], 13.21; 95% CI, 5.93-41.89) and advanced CAD (OR, 2.38; 95% CI, 1.13-4.09), and for ischemic events within the central nervous system, ICA stenosis (OR, 1.74; 95% CI, 1.01-3.16) and intracranial artery stenosis (OR, 3.01; 95% CI, 1.66-5.57). CONCLUSIONS: No differences in the prevalence of atherosclerosis of the carotid and cerebral arteries were found between patients with stable and unstable CAD in this study. Advanced CAD is one of the risk factors for hemodynamically significant cerebral artery stenosis.

Risk factor profile in patients with stroke at a young age.

Background The distribution of risk factors for stroke is related to gender and age. The main objective of study was to determine the type and frequency of stroke risk factors in patients with first-in-life stroke before the age of 50. Methods Our study included patients under the age of 50 with first-in-life stroke. The following data obtained from all participants were analyzed: a neuroimaging of the head, wide panel of blood tests, electrocardiogram, transesophageal echocardiography, ultrasound of the carotid/cerebral arteries. 24-hour ECG monitoring and angio-MRI of head were performed in most patients. Results One hundred and eighty-four patients were qualified into the study; mean age - 39 years (female 45%). The female gender was significantly more often associated with diabetes, carotid/cerebral artery stenosis, myocardial infarction, cardiomyopathy and risk factors associated with lifestyle. More than half of the patients presented at least two risk stroke factors. The most frequent categories of risk factors were related to arteries and metabolic diseases. Vascular risk factors were among the most frequent in individual age categories. Hereditary stroke-burden was significant in the patient before the age of 20.15% of the patients haven't got known stroke risk factor. Conclusions Angiopathy is the most common risk factor for stroke at a young age. More than half of the patients with stroke at a young age have at least two independent risk factors for stroke. In the first two decades of life, the most frequent risk factors for stroke are heart diseases; arterial diseases play a dominant role in the consecutive three decades.

The importance of atrial fibrillation and selected echocardiographic parameters for the effectiveness and safety of thrombolytic therapy in patients with stroke.

BACKGROUND: The efficacy and safety of thrombolytic therapy in stroke depend on multiple factors. The aim of this study was to evaluate the significance of atrial fibrillation the prognosis in terms of the functional status in patients with stroke treated with intravenous thrombolysis. An additional aim was also to assess the potential significance of reduced ejection fraction (EF) and enlarged left atrium (LA) of the heart for the prognosis in patients with stroke who underwent thrombolytic therapy. METHODOLOGY: A prospective study involved enrollment of 222 patients, mean age of 72 years with first-in-life ischemic stroke. In all participants there were realized procedures as follows: neurological status before administering rt-PA (NIHSS), selected echocardiographic parameters, functional status on the 14th day from the onset (mRankin scale) and analysis the bleeding events. RESULTS: Atrial fibrillation was significantly more frequent in women than men; females had higher CHA2DS2VASc scores and heavier neurological conditions on day 1 of stroke. Two independent factors for poor prognosis (3-5 points by mRankin) were found: the NIHSS score and the CHA2DS2VASc score ≥3. We identified 2 independent factors for death within 14 days from the onset: the result by NIHSS and the EF. The NIHSS score turned out to be the only independent predictor of hemorrhage during hospitalization: RR 1.19; CI [1.06-1.33]; p=0.003; p for model=0.0025. CONCLUSIONS: The presence of atrial fibrillation worsens the patient's prognosis in terms of the functional status and survival during the acute period of stroke in patients treated with intravenous thrombolysis. Higher NIHSS and CHA2DS2VASc scores and reduced EF in patients with stroke treated with thrombolysis are the predictors of unfavorable short-term prognosis.

Mechanical thrombectomy in acute stroke - Five years of experience in Poland.

OBJECTIVES: Mechanical thrombectomy (MT) is not reimbursed by the Polish public health system. We present a description of 5 years of experience with MT in acute stroke in Comprehensive Stroke Centers (CSCs) in Poland. METHODS AND RESULTS: We retrospectively analyzed the results of a structured questionnaire from 23 out of 25 identified CSCs and 22 data sets that include 61 clinical, radiological and outcome measures. RESULTS: Most of the CSCs (74%) were founded at University Hospitals and most (65.2%) work round the clock. In 78.3% of them, the working teams are composed of neurologists and neuro-radiologists. All CSCs perform CT and angio-CT before MT. In total 586 patients were subjected to MT and data from 531 of them were analyzed. Mean time laps from stroke onset to groin puncture was 250±99min. 90.3% of the studied patients had MT within 6h from stroke onset; 59.3% of them were treated with IV rt-PA prior to MT; 15.1% had IA rt-PA during MT and 4.7% - emergent stenting of a large vessel. M1 of MCA was occluded in 47.8% of cases. The Solitaire device was used in 53% of cases. Successful recanalization (TICI2b-TICI3) was achieved in 64.6% of cases and 53.4% of patients did not experience hemorrhagic transformation. Clinical improvement on discharge was noticed in 53.7% of cases, futile recanalization - in 30.7%, mRS of 0-2 - in 31.4% and mRS of 6 in 22% of cases. CONCLUSION: Our results can help harmonize standards for MT in Poland according to international guidelines.

Complex interventional treatment in a patient with atrial fibrillation and stroke caused by large carotid artery thrombus: a case report.

BACKGROUND: The treatment option for acute ischaemic stroke depends on the duration of symptoms, the dynamics of neurological condition changes, the aetiology, type of stroke, as well as the results of angiographic and neuroimaging tests. CASE PRESENTATION: A 60-year-old male patient presented with progressive left hemisphere stroke caused by extensive cardiogenic embolism of the common carotid artery and a thrombus closing the internal carotid artery from its ostium to the level of its intracranial division. The complex revascularisation therapy involving surgical embolectomy of the common carotid artery, thrombectomy of the internal carotid artery and intra-arterial thrombolysis has led to the improvement of arterial patency and has countered the progression of acute cerebral ischaemia. CONCLUSION: Emergency carotid embolectomy together with thrombectomy and local thrombolytic rt-PA treatment may be a reasonable rescue therapy for carefully selected patients with large-vessel acute stroke. Further research is needed to establish the advantages and safety of surgical thrombectomy in patients with acute embolic occlusion of the carotid artery and ineffectiveness of or contraindications for systemic thrombolytic treatment.

The significance of troponin elevation for the clinical course and outcome of first-ever ischaemic stroke.

BACKGROUND: An increase in the troponin I (TnI) level is a marker of myocardial damage in acute coronary syndromes (ACS) and other conditions. According to the latest reports, an increase in the concentration of TnI in the acute phase of stroke relates to 1-34% of patients. The aim of this study was to evaluate the prevalence of elevated TnI concentration in patients with acute first-ever stroke and to examine its significance for the prediction of post-stroke disability degree and death within 30 days of stroke. An additional aim of the study was to compare the anatomic location of stroke in patients with normal and elevated TnI concentrations on the 1st day of stroke. METHODS: Patients (M/F: 609/459; mean age 72 ± 11) with stroke numbering 1,068 were included in the prospective study. Their neurological deficit (National Institutes of Health Stroke Scale), TnI concentration (normal range ≤ 0.014 ng/ml), creatine kinase and ECG were examined on the 1st day of stroke. A follow-up and ECG were performed one day later in patients with abnormal TnI. The anatomical location of stroke (the right and left hemispheres and the brain stem) was compared in patients with normal and elevated TnI concentrations on the first day of stroke. The patients' functioning status was assessed using the by modified Rankin Scale (mRS) on the 30th day, and mortality was assessed within 30 days. The analysis was performed using a single and multi-factorial method of non-linear estimation for logistic regression in order to identify the independent factors for post-stroke disability at 4-6 points on the mRS on the 30th day following the onset and for death within 30 days of stroke in relation to the entire study group. The relative risk of a 4-6 point scoring on the mRS and of death among patients with abnormal TnI concentrations was also assessed. RESULTS: Abnormal TnI concentration during stroke was observed in 9.73% of patients. The functioning status (mRS) of patients with elevated TnI was significantly worse 30 days post stroke as compared to patients with normal TnI concentration. Stroke was significantly more frequent in the right-hemisphere in patients with elevated TnI and no ischaemic changes in the ECG. For patients with ACS Tn+ during stroke, the mortality within 30 days after stroke was significantly more frequent than for patients without ACS Tn+. The abnormal TnI level neurological status on the 1st day of stroke and age were independent mortality factors within 30 days following stroke. Elevated TnI concentration, hypertension and neurological status on the 1st day of stroke were independent factors for post-stroke disability. CONCLUSIONS: Elevated TnI concentration occurs in 1/10 of patients with acute ischaemic stroke. It is connected with an unfavourable course of stroke leading to a significant disability and less independence in their everyday functioning. The right hemisphere is the most common site of stroke accompanied by elevated concentration of troponin in patients with no ischaemic changes in the electrocardiogram. Troponin-positive acute coronary syndrome in the period of acute stroke increases mortality within one month. Among patients with an abnormal troponin concentration in the acute phase of stroke, poor outcome is attributed to stroke severity on admission.

Cerebral microembolism in patients with segmental left ventricular wall motion abnormalities.

BACKGROUND AND PURPOSE: The significance of segmental heart wall motion abnormalities for stroke is unknown. The aims of the study included (1) comparison of the frequency and type of embolic signals in the middle cerebral artery in patients with segmental left ventricular wall hypokinesis due to coronary heart disease with and without stroke, and (2) determination of the relationship between inflammatory parameters, fibrinogen level, dyslipidemia and microembolic signals in the middle cerebral artery in patients with segmental heart hypokinesis. MATERIAL AND METHODS: The study included 68 patients with segmental heart hypokinesis (33 without stroke [group I] and 35 with stroke [group II]), as well as 37 healthy volunteers and a reference group of 30 patients. Echocardiography and carotid/transcranial Doppler with detection of microembolic signals were performed. Patients from group I and II had erythrocyte sedimentation rate, leucocyte count, triglycerides, total cholesterol, HDL, and LDL examined. RESULTS: Embolic signals were detected in patients with segmental heart hypokinesis significantly more frequently than in the control and reference groups. The high number of embolic signals, signals of high intensity, hypokinesis of the distal part of the intraventricular septum, increased cholesterol levels, LDL and triglycerides were all found more frequently in patients from group II than in group I. Embolic signals were detected more frequently in patients with high fibrinogen levels and leukocytosis. CONCLUSIONS: Embolic signals in the middle cerebral artery in patients with segmental left ventricular hypokinesis have to be considered as a risk factor of stroke. The following changes are observed in patients with cardiogenic stroke: hypokinetic intraventricular septum, high intensity embolic signals, increased serum fibrinogen levels and leucocyte count. It may indicate the importance of these factors in the aetiology of stroke.

Segmental left ventricular hypokinesis is associated with embolic signals in transcranial Doppler.

INTRODUCTION: Global left ventricular (LV) hypokinesis is considered to be the cause of stroke, while the significance of segmental wall motion abnormalities is still unknown. OBJECTIVES: The aim of the study was to determine the frequency of embolic signals in the middle cerebral artery in patients with segmental LV wall hypokinesis in the course of coronary artery disease (CAD) with and without stroke. PATIENTS AND METHODS: The study included 68 patients (aged 21-87 years) with segmental LV wall hypokinesis (33 patients without and 35 with stroke). The reference group comprised 30 patients (aged 43-76 years) with atherosclerotic risk factors; the control group comprised 37 healthy volunteers (aged 41-71 years). All subjects underwent echocardiography and carotid and transcranial Doppler ultrasound with the detection of microembolic signals. RESULTS: Embolic signals were observed significantly more often in patients with segmental LV wall hypokinesis than in the control and reference groups. In patients with CAD and stroke, an increased number of embolic signals (≥3) was observed significantly more often compared with patients without stroke. Compared with other locations, interventricular septum and apex hypokinesis was associated with a higher frequency of embolic signals in the middle cerebral arteries. CONCLUSIONS: Segmental LV motion abnormalities in the form of hypokinesis in patients with CAD are associated with the presence of embolic signals in the middle cerebral arteries, which may have clinical significance as a risk factor for stroke.