The brain-heart connection

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.

METHODS

A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered.

STRUCTURE

Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.

METHODS

A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.

Effect of adrenalectomy on remission of subclinical left ventricular dysfunction in patients with pheochromocytoma: a speckle-tracking echocardiography study

BACKGROUND

Pheochromocytomas (PHEO) are tumours with the ability to produce, metabolize and secrete catecholamines. Catecholamines overproduction leads to the decrease of longitudinal function of the left ventricle (LV) measured by speckle-tracking echocardiography. Patients with PHEO have a lower magnitude of global longitudinal strain (GLS) than patients with essential hypertension. GLS normalization is expected after resolution of catecholamine overproduction.

METHODS

Twenty-four patients (14 females and 10 males) with a recent diagnosis of PHEO have been examined before and 1 year after adrenalectomy. An echocardiographic examination including speckle-tracking analysis with the evaluation of GLS and regional longitudinal strain (LS) in defined groups of LV segments (basal, mid-ventricular and apical) was performed.

RESULTS

One year after adrenalectomy, the magnitude of GLS increased (-14.3 ± 1.8 to -17.7 ± 1.6%; P < 0.001). When evaluating the regional LS, the most significant increase in the differences was evident in the apical segment compared to mid-ventricular and basal segments of LV (-5.4 ± 5.0 vs -1.9 ± 2.7 vs -1.6 ± 3.8; P < 0.01).

CONCLUSIONS

In patients with PHEO, adrenalectomy leads to an improvement of subclinical LV dysfunction represented by the increasing magnitude of GLS, which is the most noticeable in apical segments of LV.

Do Neurotrophins Connect Neurological Disorders and Heart Diseases?

Neurotrophins (NTs) are one of the most characterized neurotrophic factor family members and consist of four members in mammals. Growing evidence suggests that there is a complex inter- and bi-directional relationship between central nervous system (CNS) disorders and cardiac dysfunction, so-called "brain-heart axis". Recent studies suggest that CNS disorders, including neurodegenerative diseases, stroke, and depression, affect cardiovascular function via various mechanisms, such as hypothalamic-pituitary-adrenal axis augmentation. Although this brain-heart axis has been well studied in humans and mice, the involvement of NT signaling in the axis has not been fully investigated. In the first half of this review, we emphasize the importance of NTs not only in the nervous system, but also in the cardiovascular system from the embryonic stage to the adult state. In the second half, we discuss the involvement of NTs in the pathogenesis of cardiovascular diseases, and then examine whether an alteration in NTs could serve as the mediator between neurological disorders and heart dysfunction. The further investigation we propose herein could contribute to finding direct evidence for the involvement of NTs in the axis and new treatment for cardiovascular diseases.

Effects of fastigial nucleus electrostimulation on cardiac nerve regeneration, neurotransmitter release, and malignant arrhythmia inducibility in a post-infarction rat model

The reduced density of cardiac autonomic nerves plays an important role in malignant arrhythmia after myocardial infarction (MI). Previous studies have shown that there is an interaction between the brain and the heart, and fastigial nucleus electrostimulation (FNS) promotes central nerve regeneration. Whether and how it can promote cardiac nerve regeneration after MI and the underlying mechanisms remain unknown. This study investigated whether FNS promotes cardiac nerve regeneration and reduces malignant arrhythmia inducibility in a post-infarction rat model. Ninety-eight Wistar rats were randomly assigned to Sham control, MI (left anterior descending coronary artery ligation without FNS), FNS (MI plus FNS), and FNL (fastigial nucleus lesion plus FNS plus MI) groups. The frequency of malignant arrhythmia was significantly lower in the FNS group than in the MI and FNL groups. The density of cardiac autonomic nerves was less in the MI group than in the Sham group, which was promoted by FNS. The nerve growth factor (NGF) mRNA expression was downregulated in the MI group compared to the Sham group, which was significantly enhanced by FNS. The expression levels of norepinephrine (NE) and acetylcholine (ACh) were higher and lower respectively in the MI and FNL groups than in the Sham group. After FNS, NE concentration was reduced and Ach level was elevated compared to the MI group. These data suggested that FNS promoted the regeneration of cardiac autonomic nerves and reduced the incidence of malignant arrhythmias in MI rat model. The mechanisms might involve up-regulation of NGF mRNA expression, decrease of NE release and increase of ACh release.

An Internet of Medical Things-Based Model for Real-Time Monitoring and Averting Stroke Sensors

In recent years, neurological diseases have become a standout amongst all the other diseases and are the most important reasons for mortality and morbidity all over the world. The current study's aim is to conduct a pilot study for testing the prototype of the designed glove-wearable technology that could detect and analyze the heart rate and EEG for better management and avoiding stroke consequences. The qualitative, clinical experimental method of assessment was explored by incorporating use of an IoT-based real-time assessing medical glove that was designed using heart rate-based and EEG-based sensors. We conducted structured interviews with 90 patients, and the results of the interviews were analyzed by using the Barthel index and were grouped accordingly. Overall, the proportion of patients who followed proper daily heart rate recording behavior went from 46.9% in the first month of the trial to 78.2% after 3-10 months of the interventions. Meanwhile, the percentage of individuals having an irregular heart rate fell from 19.5% in the first month of the trial to 9.1% after 3-10 months of intervention research. In T5, we found that delta relative power decreased by 12.1% and 5.8% compared with baseline at 3 and at 6 months and an average increase was 24.3 ± 0.08. Beta-1 remained relatively steady, while theta relative power grew by 7% and alpha relative power increased by 31%. The T1 hemisphere had greater mean values of delta and theta relative power than the T5 hemisphere. For alpha (p < 0.05) and beta relative power, the opposite pattern was seen. The distinction was statistically significant for delta (p < 0.001), alpha (p < 0.01), and beta-1 (p < 0.05) among T1 and T5 patient groups. In conclusion, our single center-based study found that such IoT-based real-time medical monitoring devices significantly reduce the complexity of real-time monitoring and data acquisition processes for a healthcare provider and thus provide better healthcare management. The emergence of significant risks and controlling mechanisms can be improved by boosting the awareness. Furthermore, it identifies the high-risk factors besides facilitating the prevention of strokes. The EEG-based brain-computer interface has a promising future in upcoming years to avert DALY.

Incidence and Outcomes of Registry-Based Acute Myocardial Infarction After Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Acute myocardial infarction (AMI) is the rarest and least studied cardiac complication of aneurysmal subarachnoid hemorrhage (aSAH). Precise estimates of the incidence of AMI after aSAH are unavailable. Our goal was to estimate the incidence of registry-based AMI (rb-AMI) after aSAH and determine its association with clinical outcomes.

METHODS

Adult patients with aSAH in the National Inpatient Samples from 2002 to 2014 were included in the study. We evaluated risk factors for rb-AMI using univariate and multivariate regression models. Clinical outcomes that were assessed included functional status at discharge, in-patient mortality, length of stay, and total hospitalization cost, adjusting for patient demographics and cardiovascular risk factors through an inverse probability weighted analysis. Subgroup analyses were further performed stratified by rb-AMI type (ST-segment elevation myocardial infarction [STEMI] vs. non-STEMI [NSTEMI]).

RESULTS

A total of 139,734 patients with aSAH were identified, 3.6% of whom had rb-AMI. NSTEMI was the most common type of rb-AMI occurring after aSAH (71% vs. 29% for NSTEMI vs. STEMI, respectively). Patient characteristics associated with higher odds of rb-AMI included age, female sex, poor aSAH grade, and various cardiovascular risk factors. Rb-AMI was also associated with poor functional status at discharge, higher in-hospital mortality, and a longer and more costly hospital stay.

CONCLUSIONS

Rb-AMI occurs in 3.6% of patients with aSAH and is associated with poor functional status at discharge, higher in-patient mortality, and a longer and more costly hospitalization. Differentiating between different types of rb-AMI would be important in optimizing the management of patients with aSAH. Our definition of rb-AMI likely includes patients with neurogenic stress cardiomyopathy, which may confound the results.

New Imaging Signatures of Cardiac Alterations in Ischaemic Heart Disease and Cerebrovascular Disease Using CMR Radiomics

Background: Ischaemic heart disease (IHD) and cerebrovascular disease are two closely inter-related clinical entities. Cardiovascular magnetic resonance (CMR) radiomics may capture subtle cardiac changes associated with these two diseases providing new insights into the brain-heart interactions. Objective: To define the CMR radiomics signatures for IHD and cerebrovascular disease and study their incremental value for disease discrimination over conventional CMR indices. Methods: We analysed CMR images of UK Biobank's subjects with pre-existing IHD, ischaemic cerebrovascular disease, myocardial infarction (MI), and ischaemic stroke (IS) (n = 779, 267, 525, and 107, respectively). Each disease group was compared with an equal number of healthy controls. We extracted 446 shape, first-order, and texture radiomics features from three regions of interest (right ventricle, left ventricle, and left ventricular myocardium) in end-diastole and end-systole defined from segmentation of short-axis cine images. Systematic feature selection combined with machine learning (ML) algorithms (support vector machine and random forest) and 10-fold cross-validation tests were used to build the radiomics signature for each condition. We compared the discriminatory power achieved by the radiomics signature with conventional indices for each disease group, using the area under the curve (AUC), receiver operating characteristic (ROC) analysis, and paired t-test for statistical significance. A third model combining both radiomics and conventional indices was also evaluated. Results: In all the study groups, radiomics signatures provided a significantly better disease discrimination than conventional indices, as suggested by AUC (IHD:0.82 vs. 0.75; cerebrovascular disease: 0.79 vs. 0.77; MI: 0.87 vs. 0.79, and IS: 0.81 vs. 0.72). Similar results were observed with the combined models. In IHD and MI, LV shape radiomics were dominant. However, in IS and cerebrovascular disease, the combination of shape and intensity-based features improved the disease discrimination. A notable overlap of the radiomics signatures of IHD and cerebrovascular disease was also found. Conclusions: This study demonstrates the potential value of CMR radiomics over conventional indices in detecting subtle cardiac changes associated with chronic ischaemic processes involving the brain and heart, even in the presence of more heterogeneous clinical pictures. Radiomics analysis might also improve our understanding of the complex mechanisms behind the brain-heart interactions during ischaemia.

Cerebral-Cardiac Syndrome and Diabetes: Cardiac Damage After Ischemic Stroke in Diabetic State

Cerebral-cardiac syndrome (CCS) refers to cardiac dysfunction following varying brain injuries. Ischemic stroke is strongly evidenced to induce CCS characterizing as arrhythmia, myocardial damage, and heart failure. CCS is attributed to be the second leading cause of death in the post-stroke stage; however, the responsible mechanisms are obscure. Studies indicated the possible mechanisms including insular cortex injury, autonomic imbalance, catecholamine surge, immune response, and systemic inflammation. Of note, the characteristics of the stroke population reveal a common comorbidity with diabetes. The close and causative correlation of diabetes and stroke directs the involvement of diabetes in CCS. Nevertheless, the role of diabetes and its corresponding molecular mechanisms in CCS have not been clarified. Here we conclude the features of CCS and the potential role of diabetes in CCS. Diabetes drives establish a “primed” inflammatory microenvironment and further induces severe systemic inflammation after stroke. The boosted inflammation is suspected to provoke cardiac pathological changes and hence exacerbate CCS. Importantly, as the key element of inflammation, NOD-like receptor pyrin domain containing 3 (NLRP3) inflammasome is indicated to play an important role in diabetes, stroke, and the sequential CCS. Overall, we characterize the corresponding role of diabetes in CCS and speculate a link of NLRP3 inflammasome between them.

Takotsubo Syndrome: Optimizing Care with a Multidisciplinary Approach

Symptoms of takotsubo syndrome (TTS) include acute and transient regional systolic dysfunction of the left ventricle, as well as a variety of wall-motion abnormalities. The clinical features of TTS, including initial symptoms, cardiac biomarkers, and electrocardiogram (ECG) changes, are similar to those of acute coronary syndrome, with the exception that TTS patients typically have no obstructive coronary artery disease. TTS primarily affects elderly women, and emotional or physical stress is a common cause of the disease. Exaggerated sympathetic stimulation associated with dysfunction of the limbic system has also been reported to be related to TTS occurrence. Cancer also induces emotional and physical stress. Therefore, optimization of TTS care should involve cardiac, neurological, psychiatric, and oncological approaches. The first step in optimizing TTS care is to diagnose it by cardiac means. Multimodality imaging, including ECG, echocardiogram, angiography, ventriculography, and cardiac magnetic resonance imaging, is indispensable for diagnosis, therapy management, and the evaluation of prognosis in the acute and chronic phases of TTS. The current cardiac approach during the acute phase is primarily supportive, with the goal of preventing life-threatening complications. As central nervous system diseases frequently trigger TTS, a neurological approach is also required. Appropriate psychiatric medication may reduce the risk of TTS recurrence, as not only psychiatric disorders themselves but also psychiatric medications can be the trigger for TTS. Several conditions are associated with TTS, including the novel coronavirus disease 2019. We present current knowledge of TTS in this review and describe how to optimize TTS care through a multidisciplinary approach.

Neurosteroids: A novel promise for the treatment of stroke and post-stroke complications

Stroke is the primary reason for death and disability worldwide, with few treatment strategies to date. Neurosteroids, which are natural molecules in the brain, have aroused great interest in the field of stroke. Neurosteroids are a kind of steroid that acts on the nervous system, and are synthesized in the mitochondria of neurons or glial cells using cholesterol or other steroidal precursors. Neurosteroids mainly include estrogen, progesterone (PROG), allopregnanolone, dehydroepiandrosterone (DHEA), and vitamin D (VD). Most of the preclinical studies have confirmed that neurosteroids can decrease the risk of stroke, and improve stroke outcomes. In the meantime, neurosteroids have been shown to have a positive therapeutic significance in some post-stroke complications, such as epilepsy, depression, anxiety, cardiac complications, movement disorders, and post-stroke pain. In this review, we report the historical background, modulatory mechanisms of neurosteroids in stroke and post-stroke complications, and emphasize on the application prospect of neurosteroids in stroke therapy.

Multiorgan Dysfunction After Severe Traumatic Brain Injury: Epidemiology, Mechanisms, and Clinical Management

Traumatic brain injury (TBI) is a major global health problem and a major contributor to morbidity and mortality following multisystem trauma. Extracranial organ dysfunction is common after severe TBI and significantly impacts clinical care and outcomes following injury. Despite this, extracranial organ dysfunction remains an understudied topic compared with organ dysfunction in other critical care paradigms. In this review, we will: 1) summarize the epidemiology of extracranial multiorgan dysfunction following severe TBI; 2) examine relevant mechanisms that may be involved in the development of multi-organ dysfunction following severe TBI; and 3) discuss clinical management strategies to care for these complex patients.

Brain and heart-specific death in cancer patients: Population-based study

BACKGROUND

The occurrence of cardiovascular events is a major cause of death in patients with cancer. Small studies have documented a connection between specific brain alterations and autonomic cardiac dysfunctions, possibly resulting in a worse prognosis. We aimed to refine the knowledge of fatal cardiac events in patients with brain metastasis (BM).

METHODS

We performed a Surveillance, Epidemiology, and End Results SEER registry-based investigation (timeline: 2010-2016) and extracted all the advanced patients who had experienced fatal cardiac outcomes. Populations were compared according to the presence or not BM. Kaplan-Meier (KM) methodology was used for survival analysis and a multivariate model was developed by adjusting for multiple possible confounders.

RESULTS

Most related BM and cardiac death were observed at the site of lung cancer (81.4%). We extracted 3187 patients with lung cancer site, including 417 patients who had experienced fatal heart-specific with a history of BM, which is considered a BM group. The second group of heart-specific death included 2770 patients was stated as a non-BM group. Patients who had experienced heart-specific death in the BM group were predominately male, right side, upper site, and non-small type (62.11%, 54.92%, 51.56%, 69.78%), respectively. The survival outcomes between BM and the non- BM was significantly prominent (p = 0.003; median: 2 months vs. 3 months).The negative prognostic independent significance of heart-fatal events was confirmed after adjusting for multiple variables (HR = 0.76, CI = 0.68-84, p < 0.0001). The metastatic liver site was significantly associated with poorer survival rates (HR = 0.68; CI = 0.52-0.88, p = 0.005). We revealed a possible connection between the brain and heart functions.

CONCLUSIONS

The prognosis of heart-specific death patients in BM is unfavorable compared to non-BM settings in lung cancer. We may be at the gates of a new field of neurocardiooncology.

Neurohumoral Cardiac Regulation: Optogenetics Gets Into the Groove

The cardiac autonomic nervous system (ANS) is the main modulator of heart function, adapting contraction force, and rate to the continuous variations of intrinsic and extrinsic environmental conditions. While the parasympathetic branch dominates during rest-and-digest sympathetic neuron (SN) activation ensures the rapid, efficient, and repeatable increase of heart performance, e.g., during the "fight-or-flight response." Although the key role of the nervous system in cardiac homeostasis was evident to the eyes of physiologists and cardiologists, the degree of cardiac innervation, and the complexity of its circuits has remained underestimated for too long. In addition, the mechanisms allowing elevated efficiency and precision of neurogenic control of heart function have somehow lingered in the dark. This can be ascribed to the absence of methods adequate to study complex cardiac electric circuits in the unceasingly moving heart. An increasing number of studies adds to the scenario the evidence of an intracardiac neuron system, which, together with the autonomic components, define a little brain inside the heart, in fervent dialogue with the central nervous system (CNS). The advent of optogenetics, allowing control the activity of excitable cells with cell specificity, spatial selectivity, and temporal resolution, has allowed to shed light on basic neuro-cardiology. This review describes how optogenetics, which has extensively been used to interrogate the circuits of the CNS, has been applied to untangle the knots of heart innervation, unveiling the cellular mechanisms of neurogenic control of heart function, in physiology and pathology, as well as those participating to brain-heart communication, back and forth. We discuss existing literature, providing a comprehensive view of the advancement in the understanding of the mechanisms of neurogenic heart control. In addition, we weigh the limits and potential of optogenetics in basic and applied research in neuro-cardiology.

Takotsubo Cardiomyopathy: Current Treatment

Management of takotsubo syndrome (TTS) is currently empirical and supportive, via extrapolation of therapeutic principles worked out for other cardiovascular pathologies. Although it has been emphasized that such non-specific therapies for TTS are consequent to its still elusive pathophysiology, one wonders whether it does not necessarily follow that the absence of knowledge of TTS' pathophysiological underpinnings should prevent us for searching, designing, or even finding, therapies efficacious for its management. Additionally, it is conceivable that therapy for TTS may be in response to pathophysiological/pathoanatomic/pathohistological consequences (e.g., "myocardial stunning/reperfusion injury"), common to both TTS and coronary artery disease, or other cardiovascular disorders). The present review outlines the whole range of management principles of TTS during its acute phase and at follow-up, including considerations pertaining to the recurrence of TTS, and commences with the idea that occasionally management of TTS should consist of mere observation along the "first do no harm" principle, while self-healing is under way. Finally, some new therapeutic hypotheses (i.e., large doses of insulin infusions in association with the employment of intravenous short- and ultrashort-acting β-blockers) are being entertained, based on previous extensive animal work and limited application in patients with neurogenic cardiomyopathy and TTS.

Insulin and takotsubo syndrome: plausible pathophysiologic, diagnostic, prognostic, and therapeutic roles

The pathophysiology of takotsubo syndrome (TTS) is elusive. Heightened adrenergic surge via the sympathetic nervous system (mainly by norepinephrine secretion) and/or elevated blood-borne catecholamines (mainly epinephrine, secreted by the adrenals) probably mediate TTS. Patients with TTS have a low prevalence of diabetes mellitus (DM), and it has been postulated that DM, via its associated neuropathy, prevents the emergence of TTS. Insulin, in animal experiments, has been shown to greatly attenuate the effects of NE on the cardiomyocytes; also, insulin in a limited clinical experience, has been found to improve heart function in patients with neurogenic stress-cardiomyopathy and TTS. Accordingly, it is postulated that high levels of insulin encountered in patients with type 2 DM are at the roots of the protective effect of DM for the emergence of TTS. Thus, a role of insulin in the pathophysiology, diagnosis, prognosis, and therapy of TTS appears to be plausible, and needs exploration.

Risk of cardiovascular complications during non-cardiac surgery and preoperative cardiac evaluation

The preoperative evaluation of candidates to non-cardiac surgery requires a knowledge of factors related both to the type of surgery and to the risk of each patient, in order to predict the potential cardiovascular complications. Over the past several decades, the field of preoperative cardiac evaluation before non-cardiac surgery has evolved substantially on the basis of the current guidelines of international medical societies. The aim of this paper is to summarize available evidence on the risk of non-cardiac surgery, focusing on appropriate cardiovascular assessment prior to surgery.

The role of electroencephalography electrical reference in the assessment of functional brain-heart interplay: From methodology to user guidelines

BACKGROUND

The choice of EEG reference has been widely studied. However, the choice of the most appropriate re-referencing for EEG data is still debated. Moreover, the role of EEG reference in the estimation of functional Brain-Heart Interplay (BHI), together with different multivariate modelling strategies, has not been investigated yet.

METHODS

This study identifies the best methodology combining a proper EEG electrical reference and signal processing methods for an effective functional BHI assessment. The effects of the EEG reference among common average, mastoids average, Laplacian reference, Cz reference, and the reference electrode standardization technique (REST) were explored throughout different BHI methods including synthetic data generation (SDG) model, heartbeat-evoked potentials, heartbeat-evoked oscillations, and maximal information coefficient.

RESULTS

The SDG model exhibited high robustness between EEG references, whereas the maximal information coefficient method exhibited a high sensitivity. The common average and REST references for EEG showed a good consistency in the between-method comparisons. Laplacian, and Cz references significantly bias a BHI measurement.

COMPARISON WITH EXISTING METHODS

The use of EEG reference based on a common average outperforms on the use of other references for consistency in estimating directed functional BHI. We do not recommend the use of EEG references based on analytical derivations as the experimental conditions may not meet the requirements of their optimal estimation, particularly in clinical settings.

CONCLUSION

The use of a common average for EEG electrical reference is concluded to be the most appropriate choice for a quantitative, functional BHI assessment.

ST-segment elevation myocardial infarction with normal coronary arteries secondary to anterior communicating cerebral artery aneurysmal rupture: a case report

Background

Myocardial infarction (MI) with non-obstructive coronary arteries presenting with ST-segment elevation can be challenging. Understanding the cardiac and non-cardiac causes aid in identifying the underlying diagnosis and deciding on the management. Neurological insult resulting in a mismatch of oxygen supply or demand to cardiomyocytes can lead to type 2 MI. Acute brain injury, such as intracranial haemorrhage, can induce cardiac dysfunction secondary to brain–heart interaction via hypothalamic–pituitary–adrenal axis and catecholamine surge.

Case summary

A 50-year-old Caucasian male who vaped cannabis presented with epileptic seizures. A Glasgow coma scale of 7/15 necessitated urgent intubation. Electrocardiogram showed ST-segment elevation in inferior leads. Computed tomography of the head suggested intracerebral haemorrhage. He was stabilized in the intensive care unit (ICU). Subsequent imaging confirmed anterior communicating cerebral artery aneurysm and haematoma. Echocardiogram showed severe left ventricular dysfunction and hypokinesia in the left circumflex (LCx) territory. After step down from ICU, cardiac magnetic resonance imaging revealed transmural MI and myocardial oedema at LCx territory. Coronary angiogram was normal. Patient was treated with Levetiracetam and heart failure regimen. A cardiac defibrillator was implanted for secondary prevention and he was scheduled for elective neurosurgical intervention. A follow-up outpatient echocardiogram was normal.

Discussion

Myocardial infarction with non-obstructive coronary arteries is uncommon. Though the majority is due to either plaque disruption or myocarditis, non-cardiac causes, such as acute neurological insults and substance use, should be considered. Scrutinizing the clinical presentation and using a meticulous approach with appropriate investigations are required to reach the correct diagnosis and appropriate management.

Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage is a neurologic emergency that requires immediate patient stabilization and prompt diagnosis and treatment. Early measures should focus on principles of advanced cardiovascular life support. The aneurysm should be evaluated and treated in a comprehensive stroke center by a multidisciplinary team capable of endovascular and, operative approaches. Once the aneurysm is secured, the patient is best managed by a dedicated neurocritical care service to prevent and manage complications, including a syndrome of delayed neurologic decline. The goal of such specialized care is to prevent secondary injury, reduce length of stay, and improve outcomes for survivors of the disease.

Perfect storm along the neuro-cardiac axis: stroke complicated by acute biventricular dysfunction-Takotsubo syndrome or neurogenic stress cardiomyopathy?

Acute biventricular dysfunction complicating acute ischaemic stroke poses diagnostic and therapeutic challenges with respect to anticoagulation and short-term and long-term prognosis. We present the uncommon case of an elderly patient presenting with this clinical scenario, who made a full recovery on conservative therapy. Management strategies are discussed and the emerging topic of neuro-cardiac syndromes, namely neurogenic stress cardiomyopathy as distinct from Takotsubo syndrome, is explored.

Characterization of the Insular Role in Cardiac Function through Intracranial Electrical Stimulation of the Human Insula

OBJECTIVE

The link between brain function and cardiovascular dynamics is an important issue yet to be elucidated completely. The insula is a neocortical brain area that is thought to have a cardiac chronotropic regulatory function, but its role in cardiac contractility is unknown. We aimed to analyze the variability in heart rate and cardiac contractility after functional activation of different insular regions through direct electrical stimulation (E-stim) in humans.

METHODS

This was an observational, prospective study, including patients admitted for stereo-electroencephalographic recording because of refractory epilepsy, in whom the insular cortex was implanted. Patients with anatomical or electrophysiological insular abnormalities and those in whom E-stim produced subjective symptoms were excluded. Variations in heart rate (HR), stroke volume (SV), and cardiac output (CO) were analyzed during insular E-stim and compared with control E-stim of non-eloquent brain regions and sham stimulations.

RESULTS

Ten patients were included, 5 implanted in the right insula (52 E-stim) and 5 in the left (37 E-stim). Demographic and clinical characteristics of both groups were similar. E-stim of both right and left insulas induced a significant decrease of the CO and HR, and an increase of the SV. E-stim of control electrodes and sham stimulations were not associated with variations in cardiac function. Blood pressure and respiratory rate remained unaltered.

INTERPRETATION

Our results suggest a direct chronotropic and inotropic cardiac depressor function of the right and left insulas. The evidence of an insular direct cardiac regulatory function might open a path in the prevention or treatment of heart failure, arrhythmias, and sudden unexpected death in epilepsy. ANN NEUROL 2021;89:1172-1180.

Sudden Death from Primary Cerebral Melanoma: Clinical Signs and Pathological Observations

Primary cerebral tumors rarely provoke sudden death. The incidence is often underestimated with reported frequencies in the range of 0.02 to 2.1% in medicolegal autopsy series. Furthermore, primary cerebral melanoma is an uncommon neoplasm. It represents approximately 1% of all melanoma cases and 0.07% of all brain tumors. This neoplasm is very aggressive, and its annual incidence is about 1 in 10 million people. In the present study, a 20-year-old male was admitted to hospital with vomiting, headache, paresthesia and aggressive behavior. A computed tomography (CT) scan of the head was performed showing a hyperdense nodule in the right parietal lobe with inflammation of the Silvian fissure. A complete autopsy was performed 48 h after death. A blackish material was displayed on the skull base, and posterior fossa. Microscopic examination diagnosed primary brain melanoma. A systematic review of the literature was also performed where no previous analogous cases were found. The forensic pathologist rarely encounters primary cerebral melanoma, and for these reasons, it seemed appropriate to describe this case as presenting aspecific clinical symptoms and leading to sudden unexpected death. Histopathological observations are reported and discussed to explain this surprising sudden death caused by a primary cerebral melanoma.

Cardiovascular thrombotic complications in acute ischemic stroke assessed by chest spectral computed tomography during COVID-19

During the pandemic context, diagnostic algorithms had to be adapted considering the decimated medical personnel, local technical resources, and the likelihood of contamination. Given the higher probability of thrombotic complications related to COVID-19 and the availability of a dual-layer spectral computed tomography (CT) scanner, we have recently adopted the use of low-dose, non-gated, chest CT scans performed five minutes after contrast administration among patients admitted with acute ischemic stroke (AIS) undergoing cerebrovascular CT angiography. Dual-layer spectral CT comprises a single X-ray source and two-layer detector with different photon-absorption capabilities. In addition to conventional images, the two distinct energy datasets obtained enable multiparametric spectral analysis without need to change the original scanning protocol. The two spectral features that emerge as most useful for patients with AIS are virtual monoenergetic imaging and iodine-based results. Aside from the evaluation of lung parenchyma, this novel strategy enables ruling out cardioembolic sources and simultaneously providing evidence of pulmonary and myocardial injury in a single session and immediately after CT cerebrovascular angiography. Furthermore, it involves a non-invasive, seemingly accurate, unsophisticated, safer (very low radiation dose and no contrast administration), and cheaper tool for ruling out cardioembolic sources compared to transesophageal echocardiogram and cardiac CT. Accordingly, we sought to standardize the technical aspects and overview the usefulness of delayed-phase, low-dose chest spectral CT in patients admitted with AIS.

Cardiovascular autonomic dysfunction after stroke

Strokes are the paradigmatic example of the sudden impairment of the cerebral regulation of cardiac autonomic regulation. Although several aspects of dysautonomic cardiovascular regulation post stroke remain unanswered, there has been a wealth of research in this area in the last decade. In this article, we present a state-of-the-art review on the anatomical and functional organization of cardiovascular autonomic regulation, and the pathophysiology, incidence, time course, diagnosis, clinical aspects, prognosis, and management of post-stroke cardiovascular autonomic dysfunction.

Ventromedial Prefrontal Cortex Activity and Sympathetic Allostasis During Value-Based Ambivalence

Anxiety is characterized by low confidence in daily decisions, coupled with high levels of phenomenological stress. Ventromedial prefrontal cortex (vmPFC) plays an integral role in maladaptive anxious behaviors via decreased sensitivity to threatening vs. non-threatening stimuli (fear generalization). vmPFC is also a key node in approach-avoidance decision making requiring two-dimensional integration of rewards and costs. More recently, vmPFC has been implicated as a key cortical input to the sympathetic branch of the autonomic nervous system. However, little is known about the role of this brain region in mediating rapid stress responses elicited by changes in confidence during decision making. We used an approach-avoidance task to examine the relationship between sympathetically mediated cardiac stress responses, vmPFC activity and choice behavior over long and short time-scales. To do this, we collected concurrent fMRI, EKG and impedance cardiography recordings of sympathetic drive while participants made approach-avoidance decisions about monetary rewards paired with painful electric shock stimuli. We observe first that increased sympathetic drive (shorter pre-ejection period) in states lasting minutes are associated with choices involving reduced decision ambivalence. Thus, on this slow time scale, sympathetic drive serves as a proxy for "mobilization" whereby participants are more likely to show consistent value-action mapping. In parallel, imaging analyses reveal that on shorter time scales (estimated with a trial-to-trial GLM), increased vmPFC activity, particularly during low-ambivalence decisions, is associated with decreased sympathetic state. Our findings support a role of sympathetic drive in resolving decision ambivalence across long time horizons and suggest a potential role of vmPFC in modulating this response on a moment-to-moment basis.

Displaying the autonomic processing network in humans - a global tractography approach

Regulation of the internal homeostasis is modulated by the central autonomic system. So far, the view of this system is determined by animal and human research focusing on cortical and subcortical grey substance regions. To provide an overview based on white matter architecture, we used a global tractography approach to reconstruct a network of tracts interconnecting brain regions that are known to be involved in autonomic processing. Diffusion weighted imaging data were obtained from subjects of the human connectome project (HCP) database. Resulting tracts are in good agreement with previous studies assuming a division of the central autonomic system into a cortical (CAN) and a subcortical network (SAN): the CAN consist of three subsystems that encompass all cerebral lobes and overlap within the insular cortex: a parieto-anterior-temporal pathway (PATP), an occipito-posterior-temporo-frontal pathway (OPTFP) and a limbic pathway. The SAN on the other hand connects the hypothalamus to the periaqueductal grey and locus coeruleus, before it branches into a dorsal and a lateral part that target autonomic nuclei in the rostral medulla oblongata. Our approach furthermore reveals how the CAN and SAN are interconnected: the hypothalamus can be considered as the interface-structure of the SAN, whereas the insula is the central hub of the CAN. The hypothalamus receives input from prefrontal cortical fields but is also connected to the ventral apex of the insular cortex. Thus, a holistic view of the central autonomic system could be created that may promote the understanding of autonomic signaling under physiological and pathophysiological conditions.

Cardiomyocyte Injury Following Acute Ischemic Stroke: Protocol for a Prospective Observational Cohort Study

Background

Elevated cardiac troponin, which indicates cardiomyocyte injury, is common after acute ischemic stroke and is associated with poor functional outcome. Myocardial injury is part of a broad spectrum of cardiac complications that may occur after acute ischemic stroke. Previous studies have shown that in most patients, the underlying mechanism of stroke-associated myocardial injury may not be a concomitant acute coronary syndrome. Evidence from animal research and clinical and neuroimaging studies suggest that functional and structural alterations in the central autonomic network leading to stress-mediated neurocardiogenic injury may be a key underlying mechanism (ie, stroke-heart syndrome). However, the exact pathophysiological cascade remains unclear, and the diagnostic and therapeutic implications are unknown.

Objective

The aim of this CORONA-IS (Cardiomyocyte injury following Acute Ischemic Stroke) study is to quantify autonomic dysfunction and to decipher downstream cardiac mechanisms leading to myocardial injury after acute ischemic stroke.

Methods

In this prospective, observational, single-center cohort study, 300 patients with acute ischemic stroke, confirmed via cerebral magnetic resonance imaging (MRI) and presenting within 48 hours of symptom onset, will be recruited during in-hospital stay. On the basis of high-sensitivity cardiac troponin levels and corresponding to the fourth universal definition of myocardial infarction, 3 groups are defined (ie, no myocardial injury [no cardiac troponin elevation], chronic myocardial injury [stable elevation], and acute myocardial injury [dynamic rise/fall pattern]). Each group will include approximately 100 patients. Study patients will receive routine diagnostic care. In addition, they will receive 3 Tesla cardiovascular MRI and transthoracic echocardiography within 5 days of symptom onset to provide myocardial tissue characterization and assess cardiac function, 20-min high-resolution electrocardiogram for analysis of cardiac autonomic function, and extensive biobanking. A follow-up for cardiovascular events will be conducted 3 and 12 months after inclusion.

Results

After a 4-month pilot phase, recruitment began in April 2019. We estimate a recruitment period of approximately 3 years to include 300 patients with a complete cardiovascular MRI protocol.

Conclusions

Stroke-associated myocardial injury is a common and relevant complication. Our study has the potential to provide a better mechanistic understanding of heart and brain interactions in the setting of acute stroke. Thus, it is essential to develop algorithms for recognizing patients at risk and to refine diagnostic and therapeutic procedures.

Trial Registration

Clinicaltrials.gov NCT03892226; https://www.clinicaltrials.gov/ct2/show/NCT03892226.

International Registered Report Identifier (IRRID)

DERR1-10.2196/24186

A prospective study of the incidence of intracranial hemorrhage in survivors of out of hospital cardiac arrest

AIM

Intracranial Hemorrhage (ICH) is an important cause of out-of-hospital cardiac arrest (OHCA), yet there are no United States (US), European, or Australian prospective studies examining its incidence in patients who sustained OHCA. This study aims to identify the incidence of ICH in US patients with OHCA who obtain return of spontaneous circulation (ROSC).

METHODS

We prospectively analyzed consecutive patients with OHCA who achieved ROSC at a single US hospital over a 15-month period. Before beginning patient enrollment, we implemented a standardized emergency department order-set for the initial management for all patients with ROSC after OHCA. This order-set included a non-contrast head computed-tomography (NCH-CT) scan. Patient and cardiac arrest variables were recorded, as were NCH-CT findings.

RESULTS

During the study period, 85 patients sustained an OHCA, achieved ROSC, survived to hospital admission, and underwent a NCH-CT. Three of these 85 patients had ICH (3.5%). Survival to discharge was seen in 23/82 (28.0%) patients without ICH and in 1/3 patients with ICH. Survival with good neurologic outcome was seen in 14/82 (17.1%) patients without ICH and in 0/3 patients with ICH. Patients with ICH tended to be older than patients without ICH.

CONCLUSIONS

In our US cohort, ICH was an uncommon finding in patients who sustained OHCA and survived to hospital admission, and no patients with ICH survived to discharge with good neurologic outcome. Additionally, the incidence of ICH was lower than reported in previous studies.

Hemodynamics in acute stroke: Cerebral and cardiac complications

Hemodynamics is the study of blood flow, where parameters have been defined to quantify blood flow and the relationship with systemic circulatory changes. Understanding these perfusion parameters, the relationship between different blood flow variables and the implications for ischemic injury are outlined in the ensuing discussion. This chapter focuses on the hemodynamic changes that occur in ischemic stroke, and their contribution to ischemic stroke pathophysiology. We discuss the interaction between cardiovascular response and hemodynamic changes in stroke. Studying hemodynamic changes has a key role in stroke prevention, therapeutic implications and prognostic importance in acute ischemic stroke: preexisting hemodynamic and autoregulatory impairments predict the occurrence of stroke. Hemodynamic failure predisposes to the formation of thromboemboli and accelerates infarction due to impairing compensatory mechanisms. In ischemic stroke involving occlusion of a large vessel, persistent collateral circulation leads to preservation of ischemic penumbra and therefore justifying endovascular thrombectomy. Following thrombectomy, impaired autoregulation may lead to reperfusion injury and hemorrhage.

Effects of acute neurologic disease on the heart

Patients with acute neurologic disease often also have evidence of cardiac dysfunction. The cardiac dysfunction may result in a number of clinical signs including abnormal EKG changes, variations in blood pressure, development of cardiac arrhythmias, release of cardiac biomarkers, and reduced ventricular function. Although typically reversible, these cardiac complications are important to recognize as they are associated with increased morbidity and mortality. In this chapter, we discuss the suspected pathophysiology, clinical presentation, and management of the cardiac dysfunction that occur as a consequence of different types of acute neurologic illness.

Cardiac rehabilitation in Takotsubo cardiomyopathy: Predictors of utilization and effects of exercise training

BACKGROUND

Takotsubo cardiomyopathy (TCM) patients may benefit from cardiac rehabilitation (CR).

OBJECTIVES

The purpose to this study is to examine utilization of CR in TCM.

METHODS

We conducted a review of hospitalized TCM patients at Baystate Medical Center between 2010 and 2017. We evaluated rates of referral, enrollment, adherence, and changes in exercise capacity. Predictors of CR utilization were analyzed using t-test, chi-square/odds ratio and multivariable hierarchical modeling when appropriate.

RESULTS

Over 8 years, 35% of 590 patients with TCM were evaluated by phase I (inpatient) and 13.6% enrolled in phase II (outpatient) CR. Inpatient CR evaluation (OR 21, 95% CI 7-64) and cardiac catheterization (OR 5.7, 95% CI 1.9-17) were strong predictors of outpatient CR participation. Patients enrolling in CR attended 15±14 sessions and increased their exercise capacity by 1.2 METs (95% CI 0.9-1.5).

CONCLUSION

CR is inconsistently used in TCM, despite the potential physiologic benefits of exercise in TCM.

Early Serum Biomarkers for Intensive Care Unit Treatment within the First 24 Hours in Patients with Intracerebral Hemorrhage

BACKGROUND

 The prognostic significance of serum biomarkers in patients with intracerebral hemorrhage (ICH) is not well investigated concerning inhospital mortality (IHM) and cardiopulmonary events within the first 24 hours of intensive care unit (ICU) treatment. The influence of troponin I (TNI) value and cortisol value (CV) on cardiopulmonary events within the first 24 hours of ICU treatment was reported in subarachnoid hemorrhage patients, but not in ICH patients up to now. The aim of this study was to investigate the role of early serum biomarkers on IHM and TNI value and CV on cardiopulmonary events within the first 24 hours of ICU treatment.

PATIENTS AND METHODS

 A total of 329 patients with spontaneous ICH were retrospectively analyzed. Blood samples were taken on admission to measure serum biomarkers. The TNI value and CV were defined as biomarkers for cardiopulmonary stress. Demographic data, cardiopulmonary parameters, including norepinephrine application rate (NAR) in microgram per kilogram per minute and inspiratory oxygen fraction (FiO₂) within the first 24 hours, and treatment regime were analyzed concerning their impact on ICU treatment and in hospital outcome. Binary logistic analysis was used to identify independent prognostic factors for IHM.

RESULTS

 Patients with initially nonelevated CVs required higher NAR (p = 0.01) and FiO₂ (p = 0.046) within the first 24 hours of ICU treatment. Lower cholinesterase level (p = 0.004), higher NAR (p = 0.002), advanced age (p < 0.0001), larger ICH volume (p < 0.0001), presence of intraventricular hemorrhage (p = 0.007) and hydrocephalus (p = 0.009), raised level of C-reactive protein (p = 0.024), serum lactate (p = 0.003), and blood glucose (p = 0.05) on admission were significantly associated with IHM. In a multivariate model, age (odds ratio [OR]: 1.055; 95% confidence interval [CI]: 1.026-1.085; p < 0.0001), ICH volume (OR: 1.016; CI: 1.008-1.025; p < 0.0001), and Glasgow Coma Scale (GCS) score (OR: 0.680; CI: 0.605-0.764; p < 0.0001) on admission as well as requiring NAR (OR: 1.171; CI: 1.026-1.337; p = 0.02) and FiO₂ (OR: 0.951; CI: 0.921-0.983, p = 0.003) within the first 24 hours were independent predictors of IHM.

CONCLUSION

 Higher levels of C-reactive protein, serum lactate, blood glucose, and lower cholinesterase level on admission were significantly associated with IHM. Patients with initially nonelevated CVs required higher NAR and FiO₂ within the first 24 hours of ICU treatment. Furthermore, requiring an NAR > 0.5 µg/kg/min or an FiO₂ > 0.21 were identified as additional independent predictors for IHM. These results could be helpful to improve ICU treatment in ICH patients.

Reverse takotsubo cardiomyopathy caused by patent foramen ovale-related cryptogenic stroke: a case report

Background

Reverse takotsubo cardiomyopathy (rTTC) is recognized as an atypical type of TTC. It has been suggested that neurological events are typical trigger of rTTC, especially in young individuals.

Case summary

In this case report, we describe a 16-year-girl who presented with neurological deficits due to embolic stroke and acute heart failure. Transthoracic echocardiography on admission revealed a severely reduced left ventricular (LV) function with akinesis of basal to mid LV, but normal contraction in apex. Coronary computed tomography angiography confirmed unobstructed coronary arteries. Two weeks later, her LV wall motion and ejection fraction were completely normalized. Transthoracic echocardiography and transoesophageal echocardiography demonstrated no evidence of intracardiac thrombus but showed a patent foramen ovale (PFO) with large shunt. After thorough work-up and brain–heart team discussion, we concluded that the patient developed rTTC due to cryptogenic stroke related with her PFO. She underwent percutaneous PFO closure for secondary prevention with good clinical course.

Discussion

Reverse TTC is a rare condition. It should be considered in stroke patients with acute heart failure. Quick diagnosis and management with brain–heart team is crucial for better prognosis.

Early alterations in heart rate are associated with poor outcome in patients with intracerebral hemorrhage

PURPOSE

Cardiac complications are common after spontaneous intracerebral hemorrhage (ICH). In this study we intended to investigate factors associated with higher alterations in heart rate and their impact on outcome.

METHODS

Eighty-eight ICH patients were included. A simplified approach to calculate heart rate variability (HR_SD) in analogy to systolic blood pressure variability (SBP_SD) with daily standard deviations of HR in the acute (first 24 h) and subacute phase (day1-day7) was used. Using multivariable regression, factors associated with higher HR_SD and the association between higher HR_SD and poor 3-month outcome (modified Rankin Scale > 3) were analyzed. All models were adjusted for age, atrial fibrillation, mechanical ventilation, vasopressor administration, and mean HR.

RESULTS

Patients were 71 (IQR = 60-79) years old and presented with an admission ICH-Score of 2 (IQR = 1-3). In multivariable analysis, intraventricular hemorrhage (adjOR = 8.66, 95%-CI = 1.89-39.60, p = 0.005), a QRS complex >120 ms (adjOR = 19.02; 95%-CI = 2.08-175.05, p = 0.009) and female sex (adjOR = 4.24; 95%-CI = 1.08-16.64, p = 0.038) were associated with higher HR_SD in the acute phase. A higher HR_SD (adjOR = 1.29, 95%-CI = 1.01-1.66, p = 0.045) in the acute but not in the subacute phase (p = 0.764) was associated with poor 3-month outcome.

CONCLUSION

The study suggests that a higher variation in heart rate in the early phase after ICH may discriminate patients with poor outcome.

Sudden cardiac death after robbery: Homicide or natural death?

Tako-Tsubo is one of a number of rare acquired cardiomyopathies that are characterized by left ventricular dyskinesia and symptomatology typical of acute myocardial infarction (AMI). The most important feature is that the clinical features are triggered by a severe physical or emotional stress. The authors describe the story of a woman, who was brutally assaulted by two men during a house robbery and died from sudden heart failure 8 hours later, after being taken to hospital. External examination revealed no macroscopic alteration of the inner organs, whereas microscopy showed contraction bands with myocardial necrosis, subendocardial and interstitial neutrophil infiltration and fibrosis. These findings were consistent with death due to stress cardiomyopathy even in the absence of previous heart disease. The robbers were convicted of homicide and sentenced to eighteen years in prison.

Distribution and relative expression of vasoactive receptors on arteries

Arterial tone is regulated by multiple ligand-receptor interactions, and its dysregulation is involved in ischemic conditions such as acute coronary spasm or syndrome. Understanding the distribution of vasoactive receptors on different arteries may help guide the development of tissue-specific vasoactive treatments against arterial dysfunction. Tissues were harvested from coronary, mesenteric, pulmonary, renal and peripheral human artery (n = 6 samples of each) and examined using a human antibody array to determine the expression of 29 vasoactive receptors and 3 endothelin ligands. Across all types of arteries, outer diameter ranged from 2.24 ± 0.63 to 3.65 ± 0.40 mm, and AVPR1A was the most abundant receptor. The expression level of AVPR1A in pulmonary artery was similar to that in renal artery, 2.2 times that in mesenteric artery, 1.9 times that in peripheral artery, and 2.2 times that in coronary artery. Endothelin-1 was expressed at significantly higher levels in pulmonary artery than peripheral artery (8.8 times), mesenteric artery (5.3 times), renal artery (7.9 times), and coronary artery (2.4 times). Expression of ADRA2B was significantly higher in coronary artery than peripheral artery. Immunohistochemistry revealed abundant ADRA2B in coronary artery, especially vessels with diameters below 50 μm, but not in myocardium. ADRA2C, in contrast, was expressed in both myocardium and blood vessels. The high expression of ADRA2B in coronary artery but not myocardium highlights the need to further characterize its function. Our results help establish the distribution and relative levels of tone-related receptors in different types of arteries, which may guide artery-specific treatments.

Predictive Factors and Nomogram to Evaluate the Risk of Symptomatic Intracerebral Hemorrhage for Stroke Patients Receiving Thrombectomy

BACKGROUND

Symptomatic intracerebral hemorrhage (sICH) is a severe complication of mechanical thrombectomy (MT). This study is to identify predictive factors and create a nomogram to evaluate the risk of sICH after MT treatment.

METHODS

We conducted a retrospective analysis on 127 consecutive stroke patients treated by MT therapy. We evaluated multiple predictive factors for the incidence of sICH using univariate and multivariate logistic regressions. Based on the identified and other possible factors, a nomogram was constructed to predict the risk of sICH.

RESULTS

We identified several predictive factors for sICH in the univariate analysis, including thrombectomy maneuvers >3 (odds ratio [OR], 4.42; 95% confidence interval [CI], 1.25-15.6; P = 0.0211), admission blood glucose (OR, 1.29; 95% CI, 1.13-1.48; P = 0.0002), diabetes mellitus (OR, 4.44; 95% CI, 1.64-12.0; P = 0.0033), and admission National Institutes of Health Stroke Scale (NIHSS) score (OR, 1.05; 95% CI, 1.01-1.10; P = 0.0263). The multivariate analysis showed that admission NIHSS score and blood glucose significantly affected the prognosis. Moreover, the proposed nomogram showed reliable identification ability with an area under the curve of 0.82 (95% CI, 0.71-0.93), specificity of 0.745, sensitivity of 0.762, accuracy of 0.748, and negative predictive value of 0.941.

CONCLUSIONS

Our study identified the admission NIHSS score and admission blood glucose level as predictive factors for sICH. Moreover, the proposed nomogram based on possible factors showed reliable predictive performance in evaluating the risk of sICH.

Macrophage-NLRP3 Inflammasome Activation Exacerbates Cardiac Dysfunction after Ischemic Stroke in a Mouse Model of Diabetes

Ischemic stroke is one of the leading causes of death worldwide. In the post-stroke stage, cardiac dysfunction is common and is known as the brain-heart interaction. Diabetes mellitus worsens the post-stroke outcome. Stroke-induced systemic inflammation is the major causative factor for the sequential complications, but the mechanism underlying the brain-heart interaction in diabetes has not been clarified. The NLRP3 (NLR pyrin domain-containing 3) inflammasome, an important component of the inflammation after stroke, is mainly activated in M1-polarized macrophages. In this study, we found that the cardiac dysfunction induced by ischemic stroke is more severe in a mouse model of type 2 diabetes. Meanwhile, M1-polarized macrophage infiltration and NLRP3 inflammasome activation increased in the cardiac ventricle after diabetic stroke. Importantly, the NLRP3 inflammasome inhibitor CY-09 restored cardiac function, indicating that the M1-polarized macrophage-NLRP3 inflammasome activation is a pathway underlying the brain-heart interaction after diabetic stroke.

Altered limbic and autonomic processing supports brain-heart axis in Takotsubo syndrome

Aims

Takotsubo syndrome (TTS) is characterized by acute left ventricular dysfunction often triggered by emotional or physical stress. Severe activation of the sympathetic nervous system with catecholamine release caused by a dysfunctional limbic system has been proposed as a potential mechanism. We hypothesize that brain regions responsible for autonomic integration and/or limbic processing might be involved in the development of TTS. Here, we investigated alterations in resting state functional connectivity in TTS patients compared with healthy controls.

Methods and results

Using brain functional magnetic resonance imaging (fMRI), resting state functional connectivity has been assessed in 15 subjects with TTS and 39 healthy controls. Network-based statistical analyses were conducted to identify subnetworks with altered resting state functional connectivity. Sympathetic and parasympathetic networks have been constructed in addition to the default mode network and whole-brain network. We found parasympathetic- and sympathetic-associated subnetworks both showing reduced resting state functional connectivity in TTS patients compared with controls. Important brain regions constituting parasympathetic- and sympathetic-associated subnetworks included the amygdala, hippocampus, and insula as well as cingulate, parietal, temporal, and cerebellar regions. Additionally, the default mode network as well as limbic regions in the whole-brain analysis demonstrated reduced resting state functional connectivity in TTS, including the hippocampus, parahippocampal, and medial prefrontal regions.

Conclusion

For the first time, we demonstrate hypoconnectivity of central brain regions associated with autonomic functions and regulation of the limbic system in patients with TTS. These findings suggest that autonomic-limbic integration might play an important role in the pathophysiology and contribute to the understanding of TTS.

Multimorbidity and Critical Care Neurosurgery: Minimizing Major Perioperative Cardiopulmonary Complications

With increasing prevalence of chronic diseases, multimorbid patients have become commonplace in the neurosurgical intensive care unit (neuro-ICU), offering unique management challenges. By reducing physiological reserve and interacting with one another, chronic comorbidities pose a greatly enhanced risk of major postoperative medical complications, especially cardiopulmonary complications, which ultimately exert a negative impact on neurosurgical outcomes. These premises underscore the importance of perioperative optimization, in turn requiring a thorough preoperative risk stratification, a basic understanding of a multimorbid patient’s deranged physiology and a proper appreciation of the potential of surgery, anesthesia and neurocritical care interventions to exacerbate comorbid pathophysiologies. This knowledge enables neurosurgeons, neuroanesthesiologists and neurointensivists to function with a heightened level of vigilance in the care of these high-risk patients and can inform the perioperative neuro-ICU management with individualized strategies able to minimize the risk of untoward outcomes. This review highlights potential pitfalls in the intra- and postoperative neuro-ICU period, describes common preoperative risk stratification tools and discusses tailored perioperative ICU management strategies in multimorbid neurosurgical patients, with a special focus on approaches geared toward the minimization of postoperative cardiopulmonary complications and unplanned reintubation.

Echocardiographic parameters determining cardiovascular outcomes in patients after acute ischemic stroke

Previous studies have focused on only 1 or 2 echocardiographic parameters as prognostic markers in patients with acute ischemic stroke (AIS). A total of 900 patients with AIS who underwent transthoracic echocardiography (72.6 ± 12.0 years and 60% males) were retrospectively reviewed. Composite clinical events, including all-cause mortality, non-fatal stroke, non-fatal myocardial infarction, and coronary revascularization, were assessed during clinical follow-ups. During a median follow-up of 3.3 years (interquartile range 0.6-5.1 years), there were 151 (16.8%) composite events. In the multivariable analyses after controlling for potential confounders, left ventricular ejection fraction (LVEF) < 62% (hazard ratio [HR] 1.62; 95% confidence interval [CI] 1.14-2.30; p = 0.007) and AV sclerosis (AVs) (HR 1.56; 95% CI 1.10-2.21; p = 0.013) were independent prognostic factors associated with composite events. Multivariable analyses showed that HR for composite events gradually increased according to LVEF and AVs: HR was 2.6-fold higher in the highest-risk group than in the lowest group (p < 0.001). Compared with a clinical model (global chi-square = 69.6), LVEF, AVs, and both of them were significantly improved outcome prediction in sequential Cox model analysis (global chi-square = 75.6, 75.7, and 78.8, respectively; p < 0.05 for each) for each. In patients with AIS, LVEF < 62%, and the presence of AV sclerosis can predict future vascular events. Patients with AIS exhibiting reduced LVEF and AV sclerosis may benefit from aggressive secondary prevention.

Cardiovascular Manifestations and Complications of Pheochromocytomas and Paragangliomas

Pheochromocytomas and paragangliomas (PPGLs) are rare neuro-endocrine tumors. The catecholamine surge causes paroxysmal or chronic secondary hypertension. PPGLs may present as hypertensive- or PPGL-crisis with severe life-threatening cardiac and cerebrovascular complications. PPGLs-induced cardiac manifestations have been reported with diagnoses as PPGLs-induced electrocardiogram (ECG) changes “mimicking acute myocardial infarction”, arrhythmias, myocarditis, acute coronary syndrome, dilated cardiomyopathy, and lately as takotsubo syndrome. Critical analysis of these reports reveals that most of these cardiac manifestations have certain features in common. They have a dramatic clinical presentation and are reversible if the disease is treated with appropriate medical therapy and surgical resection of the PPGL tumor. They may have the same repolarization ECG changes irrespective of the clinical cardiac diagnosis, usually associated with mild to moderate elevations of myocardial biomarkers as troponins and normal coronary arteries. The histopathological findings are usually focal or multifocal in the form hypercontracted sarcomeres and contraction band necrosis (myofibrillar degeneration) with subsequent secondary mononuclear cell infiltration. Evidences argue the PPGL caused surge of catecholamines triggers hyperactivation of the sympathetic nervous system with cardiac sympathetic nerve terminal disruption with norepinephrine spillover causing the cardiac complications. A comprehensive review of various reported cardiovascular manifestations and complications of PPGLs are presented.

Quantitative assessment of consciousness during anesthesia without EEG data

Assessing the depth of anesthesia (DoA) is a daily challenge for anesthesiologists. The best assessment of the depth of anesthesia is commonly thought to be the one made by the doctor in charge of the patient. This evaluation is based on the integration of several parameters including epidemiological, pharmacological and physiological data. By developing a protocol to record synchronously all these parameters we aim at having this evaluation made by an algorithm. Our hypothesis was that the standard parameters recorded during anesthesia (without EEG) could provide a good insight into the consciousness level of the patient. We developed a complete solution for high-resolution longitudinal follow-up of patients during anesthesia. A Hidden Markov Model (HMM) was trained on the database in order to predict and assess states based on four physiological variables that were adjusted to the consciousness level: Heart Rate (HR), Mean Blood Pressure (MeanBP) Respiratory Rate (RR), and AA Inspiratory Concentration (AAFi) all without using EEG recordings. Patients undergoing general anesthesia for hernial inguinal repair were included after informed consent. The algorithm was tested on 30 patients. The percentage of error to identify the actual state among Awake, LOC, Anesthesia, ROC and Emergence was 18%. This protocol constitutes the very first step on the way towards a multimodal approach of anesthesia. The fact that our first classifier already demonstrated a good predictability is very encouraging for the future. Indeed, this first model was merely a proof of concept to encourage research ways in the field of machine learning and anesthesia.

Crosstalk between brain, lung and heart in critical care

Extracerebral complications, especially pulmonary and cardiovascular, are frequent in brain-injured patients and are major outcome determinants. Two major pathways have been described: brain-lung and brain-heart interactions. Lung injuries after acute brain damages include ventilator-associated pneumonia (VAP), acute respiratory distress syndrome (ARDS) and neurogenic pulmonary œdema (NPE), whereas heart injuries can range from cardiac enzymes release, ECG abnormalities to left ventricle dysfunction or cardiogenic shock. The pathophysiologies of these brain-lung and brain-heart crosstalk are complex and sometimes interconnected. This review aims to describe the epidemiology and pathophysiology of lung and heart injuries in brain-injured patients with the different pathways implicated and the clinical implications for critical care physicians.