Predictive Performance of Machine Learning-Based Models for Poststroke Clinical Outcomes in Comparison With Conventional Prognostic Scores: Multicenter, Hospital-Based Observational Study.

BACKGROUND: Although machine learning is a promising tool for making prognoses, the performance of machine learning in predicting outcomes after stroke remains to be examined. OBJECTIVE: This study aims to examine how much data-driven models with machine learning improve predictive performance for poststroke outcomes compared with conventional stroke prognostic scores and to elucidate how explanatory variables in machine learning-based models differ from the items of the stroke prognostic scores. METHODS: We used data from 10,513 patients who were registered in a multicenter prospective stroke registry in Japan between 2007 and 2017. The outcomes were poor functional outcome (modified Rankin Scale score >2) and death at 3 months after stroke. Machine learning-based models were developed using all variables with regularization methods, random forests, or boosted trees. We selected 3 stroke prognostic scores, namely, ASTRAL (Acute Stroke Registry and Analysis of Lausanne), PLAN (preadmission comorbidities, level of consciousness, age, neurologic deficit), and iScore (Ischemic Stroke Predictive Risk Score) for comparison. Item-based regression models were developed using the items of these 3 scores. The model performance was assessed in terms of discrimination and calibration. To compare the predictive performance of the data-driven model with that of the item-based model, we performed internal validation after random splits of identical populations into 80% of patients as a training set and 20% of patients as a test set; the models were developed in the training set and were validated in the test set. We evaluated the contribution of each variable to the models and compared the predictors used in the machine learning-based models with the items of the stroke prognostic scores. RESULTS: The mean age of the study patients was 73.0 (SD 12.5) years, and 59.1% (6209/10,513) of them were men. The area under the receiver operating characteristic curves and the area under the precision-recall curves for predicting poststroke outcomes were higher for machine learning-based models than for item-based models in identical populations after random splits. Machine learning-based models also performed better than item-based models in terms of the Brier score. Machine learning-based models used different explanatory variables, such as laboratory data, from the items of the conventional stroke prognostic scores. Including these data in the machine learning-based models as explanatory variables improved performance in predicting outcomes after stroke, especially poststroke death. CONCLUSIONS: Machine learning-based models performed better in predicting poststroke outcomes than regression models using the items of conventional stroke prognostic scores, although they required additional variables, such as laboratory data, to attain improved performance. Further studies are warranted to validate the usefulness of machine learning in clinical settings.

Cincinnati Prehospital Stroke Scale (CPSS) as a Screening Tool for Early Identification of Cerebral Large Vessel Occlusions; a Systematic Review and Meta-analysis.

Introduction: Large vessel occlusion (LVO) strokes are associated with worse functional outcomes and higher mortality rates. In the present systematic review and meta-analysis, we evaluated the diagnostic yield of the Cincinnati Prehospital Stroke Scale (CPSS) in detecting LVO. Methods: We performed an extensive systematic search among online databases including Medline, Embase, Web of Science, and Scopus, until July 31st, 2023. We also conducted a manual search on Google and Google scholar, along with citation tracking to supplement the systematic search in retrieving all studies that evaluated the diagnostic accuracy of the CPSS in detecting LVO among patients suspected to stroke. Results: Fourteen studies were included in the present meta-analysis. CPSS showed the sensitivity of 97% (95% CI: 87%-99%) and the specificity of 17% (95% CI: 4%-54%) at the cut-off point of ≥1. The optimal threshold was determined to be ≥2, with a sensitivity of 82% (95% CI: 74%-88%) and specificity of 62% (95% CI: 48%-74%) in detecting LVO. At the highest cut-off point of ≥3, the CPSS had the lowest sensitivity of 60% (95% CI: 51%-69%) and the highest specificity of 81% (95% CI: 71%-88%). Sensitivity analyses showed the robustness of the results regardless of study population, inclusion of hemorrhagic stroke patients, pre-hospital or in-hospital settings, and the definition of LVO. Conclusion: A very low level of evidence demonstrated that CPSS, with a threshold set at ≥2, is a useful tool for identifying LVO stroke and directing patients to CSCs, both in prehospital and in-hospital settings.

Estimation of the Ischemic Lesion in the Experimental Stroke Studies Using Magnetic Resonance Imaging (Review).

In translational animal study aimed at evaluation of the effectiveness of innovative methods for treating cerebral stroke, including regenerative cell technologies, of particular importance is evaluation of the dynamics of changes in the volume of the cerebral infarction in response to therapy. Among the methods for assessing the focus of infarction, MRI is the most effective and convenient tool for use in preclinical studies. This review provides a description of MR pulse sequences used to visualize cerebral ischemia at various stages of its development, and a detailed description of the MR semiotics of cerebral infarction. A comparison of various methods for morphometric analysis of the focus of a cerebral infarction, including systems based on artificial intelligence for a more objective measurement of the volume of the lesion, is also presented.

Infected Ruptured Pseudo-aneurysm in Descending Aorta; a Case Report.

Aortitis is the inflammation of the aortic wall. It can be caused by both infectious and non-infectious etiologies. Mycotic aneurysm is a rare, serious medical condition and typically requires prompt treatment with antibiotics, surgical intervention, or endovascular procedures to prevent rupture and complications. Here we reported, a 66-year-old male patient with a medical history of diabetes and hypertension, who presented to the emergency department (ED) with left-sided hemiplegia. Brain magnetic resonance imaging (MRI) revealed infarction in the right parietooccipital and left occipital lobes, demonstrating an embolic pattern. laboratory analysis revealed elevated levels of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and white blood cell (WBC). In order to investigate the possibility of sepsis, a non-contrast chest computed tomography (CT) scan was performed, which showed a soft tissue density surrounded by gas in the posterior mediastinum; for which the rupture of esophagus and infected aorta pseudoaneurysm were among differential diagnoses. To confirm the diagnosis, CT angiography was ordered. The infected ruptured pseudo-aneurysm(s) was confirmed and patient underwent thoracotomy surgery.

Cerebral Protection in Trans-Catheter Aortic Valve Replacement: Review and Contemporary Assessment of Randomized Trial Data.

As the population has aged and as aortic valve therapies have evolved, the use of trans-catheter aortic valve replacement (TAVR) has grown dramatically over the past decade. A well-known complication of percutaneous cardiac intervention is embolic phenomena, and TAVR is among the highest risk procedures for clinical and subclinical stroke. As indications for TAVR expand to lower-risk and ultimately younger patients, the long-term consequences of stroke are amplified. Cerebral embolic protection (CEP) devices have taken a on unique preventative role following the Food and Drug Administration approval of the SentinelTM Cerebral Protection System (CPS). More recently, the PROTECTED TAVR study has spurred extensive debate in the neuro-cardiac community. In this review we describe the contemporary literature regarding stroke risk associated with TAVR, the history and role of CEP devices, a PROTECTED TAVR sub-group analysis, and implications for next steps in the field. Lastly, we explore the unique need for CEP in a younger TAVR population, as well as directions for future research.

MRI Investigation of the Association of Left Atrial and Left Atrial Appendage Hemodynamics with Silent Brain Infarction.

BACKGROUND: Left atrial (LA) myopathy is thought to be associated with silent brain infarctions (SBI) through changes in blood flow hemodynamics leading to thrombogenesis. 4D-flow MRI enables in-vivo hemodynamic quantification in the left atrium (LA) and LA appendage (LAA). PURPOSE: To determine whether LA and LAA hemodynamic and volumetric parameters are associated with SBI. STUDY TYPE: Prospective observational study. POPULATION: A single-site cohort of 125 Participants of the multiethnic study of atherosclerosis (MESA), mean age: 72.3 ± 7.2 years, 56 men. FIELD STRENGTH/SEQUENCE: 1.5T. Cardiac MRI: Cine balanced steady state free precession (bSSFP) and 4D-flow sequences. Brain MRI: T1- and T2-weighted SE and FLAIR. ASSESSMENT: Presence of SBI was determined from brain MRI by neuroradiologists according to routine diagnostic criteria in all participants without a history of stroke based on the MESA database. Minimum and maximum LA volumes and ejection fraction were calculated from bSSFP data. Blood stasis (% of voxels <10 cm/sec) and peak velocity (cm/sec) in the LA and LAA were assessed by a radiologist using an established 4D-flow workflow. STATISTICAL TESTS: Student's t test, Mann-Whitney U test, one-way ANOVA, chi-square test. Multivariable stepwise logistic regression with automatic forward and backward selection. Significance level P < 0.05. RESULTS: 26 (20.8%) had at least one SBI. After Bonferroni correction, participants with SBI were significantly older and had significantly lower peak velocities in the LAA. In multivariable analyses, age (per 10-years) (odds ratio (OR) = 1.99 (95% confidence interval (CI): 1.30-3.04)) and LAA peak velocity (per cm/sec) (OR = 0.87 (95% CI: 0.81-0.93)) were significantly associated with SBI. CONCLUSION: Older age and lower LAA peak velocity were associated with SBI in multivariable analyses whereas volumetric-based measures from cardiac MRI or cardiovascular risk factors were not. Cardiac 4D-flow MRI showed potential to serve as a novel imaging marker for SBI. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY: Stage 2.

Delayed brain abscess as a complication of cerebral infarction: A rare case report and review of the literature.

INTRODUCTION: Systemic infections are a common complication of cerebral stroke, while the development of a cerebral abscess on the background of infarcted brain tissue is an extremely rare occurrence. Here, we present a new case alongside a literature review. CASE PRESENTATION: A previously healthy 37-year-old man presented with sudden right-sided weakness and speech difficulties, progressing to complete aphasia. Initial tests showed no abnormalities, but subsequent CT scans revealed left basal ganglia infarction. Despite treatment and improvement, three months later, his condition worsened, leading to surgical intervention to excision of a cerebral abscess caused by Staphylococcus aureus. Following successful surgery and treatment, the patient showed improvement and was discharged for regular follow-up care. DISCUSSION: The convergence of stroke and brain abscess poses serious clinical challenges, requiring prompt diagnosis and treatment to mitigate catastrophic consequences. Brain abscess, stemming from cerebral infection, may arise from various sources, including contiguous spread, hematogenous dissemination, or traumatic injury. Diagnosis is complicated by nonspecific radiological findings, which often lead to misdiagnosis. Risk factors include age, immunocompromised states, and certain medical conditions. Despite challenges, early detection and appropriate management, involving surgical drainage and antimicrobial therapy, are crucial for favorable outcomes. CONCLUSION: Cerebral abscess following cerebral infarction is rare but should be suspected in patients with prior stroke or hemorrhage, experiencing worsening focal deficits and consciousness. Advanced age and comorbidities increase clinical suspicion.

A case of Trousseau syndrome: Screening, detection and complication.

Trousseau syndrome (TS) is a malignant tumor-mediated complication of the hypercoagulable state with an unknown etiology. Laboratory testing results in patients with TS have indicated elevated D-dimer levels. The imaging analysis in patients who had undergone stroke has shown the presence of several cerebral infarction lesions in multiple regions. Since patients have had malignant tumors for a long time when they suffer from a secondary stroke, the optimum time for radical tumor treatment is usually missed. This study reports a case to improve the early screening and detection of TS and reduce the risk of recurrence of cerebral infarction.

Intima-Media Thickness in the Carotid Bifurcation is Related to Silent Brain Infarction: A Cross-Sectional Study.

AIMS: Carotid intima-media thickness (IMT) measurement is used to assess subclinical atherosclerosis. We aimed to examine the association between the maximum IMT by location and the occurrence of silent brain infarction (SBI). METHODS: Overall, 280 Japanese individuals (92 females, 52.6±5 years old) underwent a medical check-up at our hospital in Tokyo in 2015. Carotid IMT was measured at each site on ultrasound images (common carotid artery [CCA], internal carotid artery, or bifurcation). The risk factors for arterial dysfunction were evaluated. SBI was assessed using magnetic resonance imaging (MRI). The cross-sectional relationship between carotid maximum IMT and SBI was evaluated. RESULTS: Of the 280 individuals, 18 (6.4%) were diagnosed with SBI on MRI. The mean age of the SBI(-) and SBI(+) groups was 51.9±10.6 and 63.6±18.6 years, respectively. The correlation coefficients between the carotid maximum IMT at each location were very weak (correlation coefficient range: 0.180-0.253). The percentage of participants with SBI increased significantly with increasing maximum CCA and bIMT values. After adjusting for confounders, SBI was found to be significantly associated with the maximum bIMT (per 0.1-mm increase) (adjusted odds ratio [aOR], 1.10; 95% confidence interval [CI]: 1.03-1.17). When bIMT was categorized according to three groups (＜1.0 mm, 1.0-＜2.0 mm, and ≥ 2.0 mm), a significant SBI risk was also observed with an increase by each category of bIMT (aOR: 3.96, 95% CI: 1.63-9.52, P=0.002). CONCLUSION: The maximum bIMT was found to be the main determinant of SBI. A significant SBI risk was associated with an increase in each category of the maximum bIMT. Therefore, the maximum bIMT might be a useful predictor of future stroke in Japanese stroke-free medical check-up participants.

No Harmful Effect of Endovascular Treatment before Decompressive Surgery-Implications for Handling Patients with Space-Occupying Brain Infarction.

This study explored short- and mid-term functional outcomes in patients undergoing decompressive hemicraniectomy (DHC) due to space-occupying cerebral infarction and asked whether there is a potentially harmful effect of a priorly performed endovascular treatment (EVT). Medical records were screened for patients requiring DHC due to space-occupying cerebral infarction between January 2016 and July 2021. Functional outcomes at hospital discharge and at 3 months were assessed by the modified Rankin Scale (mRS). Out of 65 patients with DHC, 39 underwent EVT before DHC. Both groups, i.e., EVT + DHC and DHC alone, had similar volumes (280 ± 90 mL vs. 269 ± 73 mL, t-test, p = 0.633) and proportions of edema and infarction (22.1 ± 6.5% vs. 22.1 ± 6.1%, t-test, p = 0.989) before the surgical intervention. Patients undergoing EVT + DHC tended to have a better functional outcome at hospital discharge compared to DHC alone (mRS 4.8 ± 0.8 vs. 5.2 ± 0.7, Mann-Whitney-U, p = 0.061), while the functional outcome after 3 months was similar (mRS 4.6 ± 1.1 vs. 4.8 ± 0.9, Mann-Whitney-U, p = 0.352). In patients initially presenting with a relevant infarct demarcation (Alberta Stroke Program Early CT Score ≤ 5), the outcome was similar at hospital discharge and after 3 months between patients with EVT + DHC and DHC alone. This study provided no evidence for a harmful effect of EVT before DHC in patients with space-occupying brain infarction.

Craniectomía descompresiva en infarto de arteria cerebral media bilateral asociado a COVID-19. Reporte de caso / Decompressive Craniectomy in Bilateral Middle Cerebral Artery Infarction Associated with COVID-19: A Case Report

Resumen El nuevo síndrome respiratorio agudo severo por coronavirus tipo 2 (SARS-CoV-2) que causa la enfermedad por COVID-19, se detectó por primera vez en diciembre de 2019. En donde se ha visto que existe un estado protrombótico con afección al sistema nervioso central, con afectación a vasos de gran calibre como la arteria cerebral media, se debe a mecanismos inducidos por la propia infección, estado de hipercoagulabilidad y daño endotelial. Las manifestaciones neurológicas en el COVID-19 se encuentran en el 36% de los pacientes. Descripción del caso: Se trata de un paciente del sexo masculino, de 36 años de edad, con fiebre, tos y malestar general, a quien se le realizó una prueba COVID que resultó positiva, con empeoramiento del cuadro al que se agregó fotofobia, hemiparesia derecha y desviación de la comisura labial hacia la izquierda, por lo que fue llevado a un facultativo 8 horas después del inicio del cuadro clínico. Ahí se realizó una tomografía de cráneo simple que evidenció infarto extenso de la arteria cerebral media izquierda, con edema cerebral maligno, el cual se derivó a manejo quirúrgico de urgencia donde se le realizó una craniectomía descompresiva izquierda extensa. Después de esto, se mantuvo con asistencia respiratoria por intubación mecánica y medidas antiedema cerebral, y se logró que hubiera progresión ventilatoria; sin embargo, se le realizó traqueostomía y gastrostomía por presentar malos predictores de extubación. Se mantuvo en observación posquirúrgica y quedó con hemiparesia 3/5 derecha, sin algún otro déficit, por lo que se dio egreso a domicilio. Discusión: El caso presentado fue manejado con craniectomía descompresiva extensa, y se obtuvo mejoría en la supervivencia y pronóstico funcional, al igual que lo reportado en la literatura médica, en donde se recomienda que dicho manejo se realice de forma temprana. Conclusiones: El presente informe nos revela que aquellos pacientes hombres jóvenes en la cuarta y quinta década de la vida, con COVID-19 e infarto de arteria cerebral media, se presentan sin comorbilidades al darse tratamiento temprano con hemicraniectomía descompresiva, el cual mejora su pronóstico de vida, concordando con los casos presentados en la literatura médica.

Abstract The new severe acute respiratory syndrome due to coronavirus type 2 (SARS-CoV-2), which causes COVID-19 disease, was detected for the first time in December 2019. Where it has been seen that there is a prothrombotic state with involvement of the Central Nervous, with involvement of large vessels such as the middle cerebral artery, is due to mechanisms induced by the infection itself, hypercoagulable state and endothelial damage. Neurological manifestations in COVID-19 are found in 36% of patients. Case description: This is a 36-year-old male patient with fever, cough and general malaise. A COVID test was performed, which came out positive. His condition was getting worse adding photophobia, right hemiparesis and deviation of the corner of the mouth to the left, which is why he went to the doctor, arriving 8 hours after the onset of the clinical picture, where a simple skull tomography was performed, showing extensive infarction of the left middle cerebral artery with malignant cerebral edema. He was transferred to emergency surgical management where a left decompressive craniectomy was performed. After this, mechanical respiratory assistance with intubation and anti-cerebral edema measures were maintained, achieving ventilatory progression; however, a tracheostomy and gastrostomy were performed due to poor predictors of extubation. He was kept under post-surgical observation, leaving him with 3/5 right hemiparesis, without any other deficit, therefore, he was discharged home. Discussion: The case presented was managed with decompressive craniectomy, resulting in an improvement in survival, as reported in the literature where it is recommended that such management should be performed early. Conclusions: This report reveals that patients with COVID-19 present in young men in the fourth and fifth decade of life, without comorbidities, that recieved early treatment with decompressive hemicraniectomy, improved their life prognosis, consistent with the cases presented in the literature.

Association of covert brain infarct phenotype with stroke recurrence in first-ever manifest ischemic stroke according to etiology.

INTRODUCTION: Covert brain infarcts (CBI) are frequent incidental findings on MRI and associated with future stroke risk in patients without a history of clinically evident cerebrovascular events. However, the prognostic value of CBI in first-ever ischemic stroke patients is unclear and previous studies did not report on different etiological stroke subtypes. We aimed to test CBI phenotypes and their association with stroke recurrence in first-ever ischemic stroke patients according to stroke etiology. PATIENTS AND METHODS: This study is a pooled data analysis of two prospectively collected cohorts of consecutive first-ever ischemic stroke patients admitted to the comprehensive stroke centers of Bern (Switzerland) and Graz (Austria). CBI phenotypes were identified on brain MRI within 72 h after admission. All patients underwent a routine follow-up (median: 12 months) to identify stroke recurrence. RESULTS: Of 1577 consecutive ischemic stroke patients (median age: 71 years), 691 patients showed CBI on brain MRI (44%) and 88 patients had a recurrent ischemic stroke (6%). Baseline CBI were associated with stroke recurrence in multivariable analysis (HR 1.9, 95% CI 1.1-3.3). CBI phenotypes with the highest risk for stroke recurrence were cavitatory CBI in small vessel disease (SVD)-related stroke (HR 7.1, 95% CI 1.6-12.6) and cortical CBI in patients with atrial fibrillation (HR 3.0, 95% CI 1.1-8.1). DISCUSSION AND CONCLUSION: This study reports a ≈ 2-fold increased risk for stroke recurrence in first-ever ischemic stroke patients with CBI. The risk of recurrent stroke was highest in patients with cavitatory CBI in SVD-related stroke and cortical CBI in patients with atrial fibrillation.Subject terms: Covert brain infarcts, stroke.

Synchronous Superficial Middle Cerebral Vein Outflow Correlates Favorable Tissue Fate After Mechanical Thrombectomy for Acute Ischemic Stroke.

RATIONALE AND OBJECTIVES: The purpose of this study was to determine the association between hemispheric synchrony in venous outflow at baseline and tissue fate after mechanical thrombectomy (MT) for acute ischemic stroke (AIS). MATERIALS AND METHODS: A two-center retrospective analysis involving AIS patients who underwent MT was performed. The four cortical veins of interest include the superficial middle cerebral vein (SMCV), sphenoparietal sinus (SS), vein of Labbé (VOL), and vein of Trolard (VOT). Baseline computed tomography perfusion data were used to compare the following outflow parameters between the hemispheres: first filling time (△FFT), time to peak (△TTP) and total filling time (△TFT). Synchronous venous outflow was defined as △FFT = 0. Multivariable regression analyses were performed to evaluate the association of venous outflow synchrony with penumbral salvage, infarct growth, and intracranial hemorrhage (ICH) after MT. RESULTS: A total of 151 patients (71.4 ± 13.2 years, 65.6% women) were evaluated. Patients with synchronous SMCV outflow demonstrated significantly greater penumbral salvage (41.3 mL vs. 33.1 mL, P = 0.005) and lower infarct growth (9.0 mL vs. 14.4 mL, P = 0.015) compared to those with delayed SMCV outflow. Higher △FFTSMCV (ß = -1.44, P = 0.013) and △TTPSMCV (ß = -0.996, P = 0.003) significantly associated with lower penumbral salvage, while higher △FFTSMCV significantly associated with larger infarct growth (ß = 1.09, P = 0.005) and increased risk of ICH (odds ratio [OR] = 1.519, P = 0.047). CONCLUSION: Synchronous SMCV outflow is an independent predictor of favorable tissue outcome and low ICH risk, and thereby carries the potential as an auxiliary radiological marker aiding the treatment planning of AIS patients.

Deep learning reconstruction for improving the visualization of acute brain infarct on computed tomography.

PURPOSE: This study aimed to investigate the impact of deep learning reconstruction (DLR) on acute infarct depiction compared with hybrid iterative reconstruction (Hybrid IR). METHODS: This retrospective study included 29 (75.8 ± 13.2 years, 20 males) and 26 (64.4 ± 12.4 years, 18 males) patients with and without acute infarction, respectively. Unenhanced head CT images were reconstructed with DLR and Hybrid IR. In qualitative analyses, three readers evaluated the conspicuity of lesions based on five regions and image quality. A radiologist placed regions of interest on the lateral ventricle, putamen, and white matter in quantitative analyses, and the standard deviation of CT attenuation (i.e., quantitative image noise) was recorded. RESULTS: Conspicuity of acute infarct in DLR was superior to that in Hybrid IR, and a statistically significant difference was observed for two readers (p ≤ 0.038). Conspicuity of acute infarct with time from onset to CT imaging at < 24 h in DLR was significantly improved compared with Hybrid IR for all readers (p ≤ 0.020). Image noise in DLR was significantly reduced compared with Hybrid IR with both the qualitative and quantitative analyses (p < 0.001 for all). CONCLUSION: DLR in head CT helped improve acute infarct depiction, especially those with time from onset to CT imaging at < 24 h.

Ovarian hyperstimulation syndrome with carotid artery dissection and cerebral infarction: a case report.

BACKGROUND AND PURPOSE: Ovarian hyperstimulation syndrome (OHSS) is one of the most serious iatrogenic complications in assisted reproductive technology, which seem rarely associated with cerebrovascular diseases. We reported a patient diagnosed with OHSS combined with carotid artery dissection and massive cerebral infarction. CASE PRESENTATION: We reported a unique case of a 31-year-old woman who experienced abdominal pain, blurred consciousness, and speech inability after 15-day continuous injection of human gonadotropin for infertility. Imaging examination showed hyperacute cerebral infarction in the left frontotemporal island parietal lobe and left internal carotid artery dissection. After therapeutic use of low-molecular-weight heparin calcium anticoagulation and other conventional cerebrovascular treatments, she eventually achieved a good prognosis. CONCLUSIONS: OHSS seemd rarely associated with cerebrovascular diseases, such as infarction and carotid artery dissection. Encountering abdominal symptoms combined with neurologic symptoms, a detailed history and a thorough examination are essential. It is necessary to comprehensively analyze the pathogenesis and formulate individualized therapy according to the specific conditions of patients.

Spontaneous splenic rupture due to occult signet-ring cell gastric cancer accompanied by a bulky splenic vein thrombosis and postoperative brain infarction: A case report.

Background: Splenic rupture because of metastasis from a distant organ is extremely rare. Case Presentation: An 80-year-old man presented with left flank pain. A computed tomography (CT) demonstrated a poorly enhanced enlarged spleen with bulky thrombus in the splenic vein without extravasations. A CT on the following day showed increased intraperitoneal hemorrhage; therefore, an emergency laparotomy was performed. The spleen was enlarged and ruptured with lacerations on its surface. Macroscopic examination showed congestion with a thrombus in the splenic vein around the hilum. Pathology revealed signet-ring cell carcinoma. On the third postoperative day, a massive cerebral infarction in the left middle cerebral artery was revealed. Endoscopic examination demonstrated normal gastric mucosa except for some erosions, for which biopsies were performed, and two of five specimens encompassed signet-ring cell carcinoma in the lamina propria. Conclusion: Occult cancer could result in a drastic manifestation of its metastasis accompanying systemic thrombotic events.

The Development of Neurological Damage in a Patient With Thrombotic Thrombocytopenic Purpura and Legionnaires' Disease: A Case Report.

This case report aims to highlight a rare and severe presentation of Legionnaires' disease complicated by thrombotic thrombocytopenic purpura (TPP). The patient, a 75-year-old male with a history of COVID-19 infection, presented with bilateral pneumonia positive for Legionella pneumophila. He developed signs of TTP, cerebral hemorrhage, and renal failure. Despite treatment, the patient's condition deteriorated, leading to flaccid paralysis, absent reflexes, and multiple brain hemorrhages. This case suggests a potential autoimmune mechanism for the neurological symptoms seen in this combination of Legionnaires' disease and TTP. Thus, it would be worthwhile to further investigate and understand the relationship between these two conditions. Further research into underlying mechanisms will contribute to improving therapeutic approaches for this rare presentation. Additionally, the patient's previous COVID-19 infection could have contributed to thrombotic complications due to its association with respiratory infections, warranting further investigation.

Greater burden of white matter lesions and silent infarcts ipsilateral to carotid stenosis.

OBJECTIVES: Carotid stenosis may cause silent cerebrovascular disease (CVD) through atheroembolism and hypoperfusion. If so, revascularization may slow progression of silent CVD. We aimed to compare the presence and severity of silent CVD to the degree of carotid bifurcation stenosis by cerebral hemisphere. MATERIALS AND METHODS: Patients age ≥40 years with carotid stenosis >50% by carotid ultrasound who underwent MRI brain from 2011-2015 at Mayo Clinic were included. Severity of carotid stenosis was classified by carotid duplex ultrasound as 50-69% (moderate), 70-99% (severe), or occluded. White matter lesion (WML) volume was quantified using an automated deep-learning algorithm applied to axial T2 FLAIR images. Differences in WML volume and prevalent silent infarcts were compared across hemispheres and severity of carotid stenosis. RESULTS: Of the 183 patients, mean age was 71±10 years, and 39.3% were female. Moderate stenosis was present in 35.5%, severe stenosis in 46.5% and occlusion in 18.0%. Patients with carotid stenosis had greater WML volume ipsilateral to the side of carotid stenosis than the contralateral side (mean difference, 0.42±0.21cc, p=0.046). Higher degrees of stenosis were associated with greater hemispheric difference in WML volume (moderate vs. severe; 0.16±0.27cc vs 0.74±0.31cc, p=0.009). Prevalence of silent infarct was 23.5% and was greater on the side of carotid stenosis than the contralateral side (hemispheric difference 8.8%±3.2%, p=0.006). Higher degrees of stenosis were associated with higher burden of silent infarcts (moderate vs severe, 10.8% vs 31.8%; p=0.002). CONCLUSIONS: WML and silent infarcts were greater on the side of severe carotid stenosis.

Management of covert brain infarction survey: A call to care for and trial this neglected population.

BACKGROUND: Covert brain infarction (CBI) is highly prevalent and linked with stroke risk factors, increased mortality, and morbidity. Evidence to guide management is sparse. We sought to gain information on current practice and attitudes toward CBI and to compare differences in management according to CBI phenotype. METHODS: We conducted a web-based, structured, international survey from November 2021 to February 2022 among neurologists and neuroradiologists. The survey captured respondents' baseline characteristics, general approach toward CBI and included two case scenarios designed to evaluate management decisions taken upon incidental detection of an embolic-phenotype and a small-vessel-disease phenotype. RESULTS: Of 627 respondents (38% vascular neurologists, 24% general neurologists, and 26% neuroradiologists), 362 (58%) had a partial, and 305 (49%) a complete response. Most respondents were university hospital senior faculty members experienced in stroke, mostly from Europe and Asia. Only 66 (18%) of respondents had established institutional written protocols to manage CBI. The majority indicated that they were uncertain regarding useful investigations and further management of CBI patients (median 67 on a slider 0-100, 95% CI 35-81). Almost all respondents (97%) indicated that they would assess vascular risk factors. Although most would investigate and treat similarly to ischemic stroke for both phenotypes, including initiating antithrombotic treatment, there was considerable diagnostic and therapeutic heterogeneity. Less than half of respondents (42%) would assess cognitive function or depression. CONCLUSIONS: There is a high degree of uncertainty and heterogeneity regarding management of two common types of CBI, even among experienced stroke physicians. Respondents were more proactive regarding the diagnostic and therapeutic management than the minimum recommended by current expert opinions. More data are required to guide management of CBI; meantime, more consistent approaches to identification and consistent application of current knowledge, that also consider cognition and mood, would be promising first steps to improve consistency of care.