Underlying embolic and pathologic differentiation by cerebral microbleeds in cryptogenic stroke.

BACKGROUND: Cryptogenic stroke encompasses diverse emboligenic mechanisms and pathogeneses. Cerebral microbleeds (CMBs) occur differently among stroke subtypes. The association of CMBs with cryptogenic stroke is essentially unknown. METHODS: CHALLENGE ESUS/CS (Mechanisms of Embolic Stroke Clarified by Transesophageal Echocardiography for ESUS/CS) is a multicenter registry with comprehensive data including gradient-echo T2*-weighted magnetic resonance imaging of cryptogenic stroke patients who underwent transesophageal echocardiography. Patients' clinical characteristics were compared according to the presence and location of CMBs. RESULTS: A total of 661 patients (68.7 ± 12.7 years; 445 males) were enrolled, and 209 (32%) had CMBs. Age (odds ratio [OR] 1.02, 95% confidence interval [CI] 1.00-1.04, p = 0.020), male sex (OR 1.85, 95% CI 1.18-2.91, p = 0.007), hypertension (OR 1.71, 95% CI 1.03-2.86, p = 0.039), chronic kidney disease (OR 1.64, 95% CI 1.11-2.43, p = 0.013), deep and subcortical white matter hyperintensity (OR 1.82, 95% CI 1.16-2.85, p = 0.009), and periventricular hyperintensity (OR 2.18, 95% CI 1.37-3.46, p = 0.001) were independently associated with the presence of CMBs. Aortic complicated lesions (OR 1.78, 95% CI 1.12-2.84, p = 0.015) were associated with deep and diffuse CMBs, whereas prior anticoagulant therapy (OR 7.88, 95% CI, 1.83-33.9, p = 0.006) was related to lobar CMBs. CONCLUSIONS: CMBs were common, and age, male sex, hypertension, chronic kidney disease, and cerebral white matter diseases were related to CMBs in cryptogenic stroke. Aortic complicated lesions were associated with deep and diffuse CMBs, while prior anticoagulant therapy was related to lobar CMBs.

Associations of High Intensities on Magnetization-Prepared Rapid Acquisition with Gradient Echo with Aortic Complicated Lesions in Ischemic Stroke Patients.

BACKGROUND: Aortic complicated lesions (ACLs) are key parameters for evaluating aortic embolic sources in embolic stroke, and are usually diagnosed using transesophageal echocardiography (TEE). However, alternative methods for diagnosing ACLs have not been well established. We investigated associations between high-intensity areas on T1-weighted imaging (T1WI) with magnetization-prepared rapid acquisition with gradient echo (MPRAGE) and ACLs on TEE among ischemic stroke patients. METHODS: Participants comprised 135 patients (mean age, 71 years; 35 women) with ischemic stroke or transient ischemic attack who underwent TEE for evaluation of embolic sources and plaque imaging using MPRAGE for evaluation of aortic or carotid plaques. Aortic plaque with signal intensity ≥200% of sternocleidomastoid intensity on MPRAGE was categorized as "high intensity". ACLs on TEE were defined by focal increases in intima-media thickness (IMT) ≥4.0 mm or the presence of ulcerated or mobile plaques. RESULTS: Fifty-six patients (42%) showed high-intensity areas on MPRAGE at the aortic arch. Aortic maximum IMT was significantly higher in patients with high intensities than in those without (p < 0.001). Incidences of ACLs (66 vs. 20%, p < 0.001) or ulcerated or mobile plaques (30 vs. 6%, p < 0.001) were significantly higher in patients with high intensities than in patients without. Multivariable logistic regression analysis showed that high intensities on MPRAGE were independently associated with the presence of ACLs (OR 5.72; 95% CI 2.38-13.70) and ulcerated or mobile plaques (OR 4.18; 95% CI 1.29-13.50). CONCLUSIONS: High intensities on T1WI with MPRAGE in the aortic arch were significantly associated with the presence of ACLs. An evaluation of the aortic arch using MPRAGE may be useful for predicting ACLs.

A Novel Evaluation for Predicting Aortic Complicated Lesions Using Calcification on Chest X-ray.

BACKGROUND: The aorta is a significant source of cerebral thromboembolisms. Aortic complicated lesions (ACLs) are key findings on transesophageal echocardiography (TEE) for assessing aortic sources of emboli to the brain. TEE is sometimes avoided due to its invasiveness. However, few reports have examined alternative methods for predicting ACLs. We investigated relationships between aortic arch calcification (AAC) on chest X-ray and ACLs. METHODS: Participants comprised 300 patients with acute ischemic stroke or transient ischemic attack who underwent TEE for the evaluation of the aortic arch and heart. A postero-anterior plain chest X-ray in the recumbent position was evaluated on admission for each patient. AAC was evaluated using 4 grades (0-3) and "AAC thickness" defined as the distance from the inner margin of the most distant AAC to the outer margin of the aortic vessel wall. ACLs were defined by intima-media thickness (IMT) ≥4.0 mm or presence of ulcerated or mobile plaques. Carotid maximum IMT on ultrasonography was also evaluated. Comparison of the diagnostic ability to predict ACL was performed between AAC grades and AAC thickness or AAC thickness and carotid maximum IMT using the Delong method. RESULTS: ACLs were identified in 71 patients (23.7%), including ACLs with ulcerated plaques in 24 (8.0%) and ACLs with mobile plaques in 9 (3.0%). Plaque thickness was greater in higher AAC grades or higher quartiles of AAC thickness (p for trend <0.001 each). The Cochran-Armitage test showed that both higher AAC grade and higher quartile of AAC thickness were significantly associated with the presence of ACLs, as well as the presence of ulcerated or mobile plaques (p for trend < 0.001 each). Receiver-operating characteristic (ROC) analysis showed optimal cut-off values for AAC thickness of 5.6 mm for ACLs and 6.0 mm for ulcerated or mobile plaques. Multivariate logistic regression revealed a higher grade of AAC (grades 2-3) and AAC thickness (≥6 mm) as significantly associated with ACLs and ulcerated or mobile plaques (p < 0.001 each). ROC curve comparisons showed that AAC thickness offered a better marker of ACLs than AAC grade (p = 0.019), although no significant difference was evident between AAC thickness and carotid maximum IMT (p = 0.567). CONCLUSIONS: AAC on chest X-ray, evaluated by both AAC grade and AAC thickness to the outer aortic vessel wall, was significantly associated with ACLs on TEE. AAC thickness was suggested as more useful than AAC grade and equivalent to carotid IMT in predicting ACLs.

Lesión complicada por picadura del pez león (Pterois volitans) / Complicated lesions after the sting of the Lionfish (Pterois volitans)

Se presenta el caso de un buzo profesional, de la raza blanca, de 29 años de edad, con antecedentes patológicos personales de obesidad exógena grado I, quien acude al hospital con lesión complicada por picadura del pez león (Pterois volitans) en el miembro inferior izquierdo (cara anteromedial de la pierna), de 21 días de evolución, durante una actividad de corte y soldadura subacuática, en aguas turbias a una profundidad entre 4 y 5 m. Se refieren los síntomas siguientes: dolor intenso con irradiación e hipoestesia, signos de celulitis y linfangitis de evolución tórpida hacia la necrosis e infección de la herida por la aplicación incorrecta de la terapéutica médica inicial. Se indicó tratamiento médico con antibioticoterapia, analgésicos, antinflamatorios y antihistamínicos por vía oral y tratamiento quirúrgico con necrectomía, curas locales y cierre de la herida por colgajo; se adjuntó la oxigenación hiperbárica para la estimulación de la reparación, defensa y cicatrización de los tejidos lesionados. El conocimiento acerca del tema permite actuar con precaución ante las manifestaciones clínicas y sus complicaciones. La aplicación de la oxigenación hiperbárica posibilita disminuir el tiempo de evolución y la reincorporación rápida del paciente a su labor.

Twenty-nine years old white professional diver with personal pathological antecedents of Type I exogenous obesity who presents to the hospital with a complicated bite of lionfish (Pterois volitans) in the left lower limb (anteromedial part of the leg) of 21 days evolution. The patient was bitten during an underwater activity of cutting and welding in muddy waters at a depth between 4 and 5 meters. He reports the following symptoms: acute pain with irradiation and hypoesthesia, signs of cellulitis and lymphangitis of torpid evolution towards the necrosis and infection of the wound as a result of an incorrect initial medical therapy. Medical treatment with antibiotics, analgesics, antinflammatories and antihistamines per mouth was indicated and surgical treatment with Necrectomy, local cures and flap for wound closure was employed. Hyperbaric oxygenation for the stimulation of the repair, defense and cicatrisation of the injured tissues was included. The knowledge about this topic allows acting with caution considering the clinical manifestations and its complications. The use of hyperbaric oxygenation makes the diminishment of the time of evolution and the return of the patient to work possible.

Lesión complicada por picadura del pez león (Pterois volitans) / Complicated lesions after the sting of the Lionfish (Pterois volitans)

Se presenta el caso de un buzo profesional, de la raza blanca, de 29 años de edad, con antecedentes patológicos personales de obesidad exógena grado I, quien acude al hospital con lesión complicada por picadura del pez león (Pterois volitans) en el miembro inferior izquierdo (cara anteromedial de la pierna), de 21 días de evolución, durante una actividad de corte y soldadura subacuática, en aguas turbias a una profundidad entre 4 y 5 m. Se refieren los síntomas siguientes: dolor intenso con irradiación e hipoestesia, signos de celulitis y linfangitis de evolución tórpida hacia la necrosis e infección de la herida por la aplicación incorrecta de la terapéutica médica inicial. Se indicó tratamiento médico con antibioticoterapia, analgésicos, antinflamatorios y antihistamínicos por vía oral y tratamiento quirúrgico con necrectomía, curas locales y cierre de la herida por colgajo; se adjuntó la oxigenación hiperbárica para la estimulación de la reparación, defensa y cicatrización de los tejidos lesionados. El conocimiento acerca del tema permite actuar con precaución ante las manifestaciones clínicas y sus complicaciones. La aplicación de la oxigenación hiperbárica posibilita disminuir el tiempo de evolución y la reincorporación rápida del paciente a su laborAU)

Twenty-nine years old white professional diver with personal pathological antecedents of Type I exogenous obesity who presents to the hospital with a complicated bite of lionfish (Pterois volitans) in the left lower limb (anteromedial part of the leg) of 21 days evolution. The patient was bitten during an underwater activity of cutting and welding in muddy waters at a depth between 4 and 5 meters. He reports the following symptoms: acute pain with irradiation and hypoesthesia, signs of cellulitis and lymphangitis of torpid evolution towards the necrosis and infection of the wound as a result of an incorrect initial medical therapy. Medical treatment with antibiotics, analgesics, antinflammatories and antihistamines per mouth was indicated and surgical treatment with Necrectomy, local cures and flap for wound closure was employed. Hyperbaric oxygenation for the stimulation of the repair, defense and cicatrisation of the injured tissues was included. The knowledge about this topic allows acting with caution considering the clinical manifestations and its complications. The use of hyperbaric oxygenation makes the diminishment of the time of evolution and the return of the patient to work possible(AU)