Super Formula for Soluble C-Type Lectin-Like Receptor 2 × D-Dimer in Patients With Acute Cerebral Infarction

Acute cerebral infarction (ACI) includes atherosclerotic and cardiogenic ACI and involves a thrombotic state, requiring antithrombotic treatment. However, the thrombotic state in ACI cannot be evaluated using routine hemostatic examinations. Plasma soluble C-type lectin-like receptor 2 (sCLEC-2) and D-dimer levels were measured in patients with ACI. Plasma sCLEC-2 and D-dimer levels were significantly higher in patients with ACI than in those without it. The sCLEC-2 × D-dimer formula was significantly higher in patients with ACI than in those without it. A receiver operating characteristic curve showed a high sensitivity, area under the curve, and odds for diagnosing ACI in the sCLEC-2 × D-dimer formula. Although the sCLEC-2 and D-dimer levels were useful for the differential diagnosis between cardiogenic and atherosclerotic ACI, the sCLEC-2 × D-dimer formula was not useful. sCLEC2 and D-dimer levels are useful for the diagnosis of ACI and the sCLEC2 × D-dimer formula can enhance the diagnostic ability of ACI, and sCLEC2 and D-dimer levels may be useful for differentiating between atherosclerotic and cardioembolic ACI.

Prognostic Significance of Asymptomatic Cerebral Infarction in Patients After Cardiac Catheterization

Recent studies have showed that asymptomatic cerebral infarction (ACI) developed in a reasonable number of patients after cardiac catheterization. However, no study has investigated the long-term prognostic impact of ACI after cardiac catheterization. We investigated whether ACI after cardiac catheterization affects long-term mortality and subsequent cardiovascular events.We retrospectively enrolled patients who underwent cardiac catheterization before cardiac surgery and cerebral diffusion-weighted magnetic resonance imaging (DWI). The incidence and clinical features of ACI were investigated. The long-term prognosis, including all-cause mortality and subsequent major cardiovascular events (MACE; all-cause mortality, stroke, acute myocardial infarction, fatal arrhythmia, and hospitalized heart failure), was also assessed.A total of 203 patients were enrolled. Of these, 10.3% had ACI diagnosed by DWI. There were no differences in baseline characteristics between patients with and without ACI, except more frequent history of symptomatic stroke in patients with ACI. In the Kaplan-Meier analysis during a median follow-up of 1009 days, the patients with ACI showed worse mortality and a slightly higher occurrence of MACE compared with those without ACI (P = 0.01 and P = 0.08, respectively). In addition, ACI was a prognostic marker independent of age, surgery type, and history of stroke.ACI after cardiac catheterization frequently developed and was also associated with long-term prognosis. It may be an independent prognostic marker in high-risk patients who underwent subsequent cardiac surgery.

Development of a model for predicting acute cerebral infarction induced by non-variceal upper gastrointestinal bleeding

OBJECTIVE

To evaluate the risk factors for acute cerebral infarction(ACI) in patients with non-variceal upper gastrointestinal bleeding(NVUGIB), and construct a model for predicting ACI in NVUGIB patients.

METHODS

A model for predicting ACI induced by NVUGIB was established on the basis of a retrospective study that involved 1282 patients who were diagnosed with NVUGIB in the emergency department and Gastroenterology Department of Nanchang University Affiliated Ganzhou Hospital from January 2019 to December 2021. Receiver operating characteristic (ROC) curves were drawn to evaluate the sensitivity and specificity of the model and CHA2DS2-VASc score to predict ACI. Delong's test was used to compare AUCs of the present score and the CHA2DS2-VASc score.

RESULTS

There were 1282 patients enrolled in the study, including 69 in the ACI group and 1213 in the non-ACI group. Multivariate analysis revealed that hypertension, diabetes, red blood cell (RBC) transfusion, mechanical ventilation, D-dimer, rate pressure product (RPP), somatostatin and mean platelet volume (MPV) were factors associated with ACI induced by NVUGIB. A model based on the eight factors was established, Logit(P)= 0.265 + 1.382 × 1 + 1.120 × 2 + 1.769 × 3 + 0.839 × 4-1.549 × 5-0.361 × 6 + 0.045 × 7 + 1.158 × 8(or 1.069 ×9) (X1, hypertension=1; X2, diabetes=1; X3, RBC transfusion=1; X4, mechanical ventilation=1; X5, somatostatin=1; X6, MPV(fL); X7, D-dimer(ng/l); X8, low RPP= 1; X9, high RPP = 2). The area under ROC curve of the model was 0.873, the sensitivity and specificity were 0.768 and 0.887, respectively. The area under ROC curve of CHA2DS2-VASc score was 0.792, the sensitivity and specificity were 0.728 and 0.716, respectively. Delong's test showed the area under ROC curve of the present study was significantly larger than that of CHA2DS2-VASc score.

CONCLUSIONS

Hypertension, diabetes, RBC transfusion, mechanical ventilation, D-dimer, RPP, somatostatin and MPV were factors associated with ACI induced by NVUGIB. A model constructed based on these factors showed excellent prediction of ACI, and was superior to CHA2DS2-VASc score. However, this needs to be further validated by multi-center study with a larger sample size.

Predictive value of P wave parameters, indices, and a novel electrocardiographic marker for silent cerebral infarction and future cerebrovascular events

BACKGROUND

Silent cerebral infarction (SCI) is a neuronal injury without a clinically apparent stroke or transient ischaemic attack. Left atrial cardiomyopathy is closely associated with SCI. P wave changes in the electrocardiogram (ECG) provide significant information about the development of atrial cardiomyopathy. This study evaluated the role of P wave parameters and indices and a novel ECG parameter in predicting SCI, future cerebrovascular events, and atrial fibrillation/flutter.

MATERIALS AND METHODS

A total of 272 patients were retrospectively screened and divided into two groups according to SCI. Cerebrovascular events and atrial fibrillation/flutter were defined as the study's outcomes. P wave parameters, indices, and a novel ECG parameter called the P wave ratio (PWR) were calculated from ECGs, and the relationship between SCI and outcomes was investigated.

RESULTS

The maximum P wave duration (PWD), P wave dispersion (PWdisp), PWD measured from the D2 lead (PWDD2), P wave peak time measured from the D2 lead (PWPTD2), PWPT measured from the V1 lead (PWPTV1), and P wave terminal force (PWTFV1) were significantly longer in the SCI group. Both partial and advanced inter atrial block (IAB) were significantly high in the SCI group. The novel parameter P wave ratio (PWR) was significantly longer in the SCI group (0.55 ± 0.08 vs. 0.46 ± 0.09; p < 0.001). In multivariate regression analysis, PWdisp (OR: 1.101, p < 0.001), PWPTD2 (OR: 1.095, p = 0.017), and PWR (OR: 1.231, p < 0.001) were found to be independent predictors of SCI. Cox regression analysis revealed that the PWR (HR 1.077; 95% CI 1.029-1.128; p = 0.001) was associated with cerebrovascular events and atrial fibrillation/flutter.

CONCLUSION

In our study, we observed that PWR could be a valuable parameter for predicting SCI and future cerebrovascular events.

A - 77 Case Study of Bilateral Thalamic Infarction with Persistent Cognitive and Behavioral Symptoms

OBJECTIVE

Bilateral thalamic infarction due to artery of Percheron (AOP) occlusion is rare (0.01-2% of all ischemic strokes) and neuropsychological sequelae are not well-defined. We present the case of a 50-year-old, right-handed, Caucasian woman, with 12 years of education, who presented with cognitive and behavioral symptoms following AOP stroke.

METHOD

Following AOP stroke, the patient experienced seven-day hospitalization and one-month subacute rehabilitation. Symptoms after discharge from the latter included vertical gaze palsy, mild balance difficulties, impulsivity, and amnesia (retrograde and anterograde). Compared to neuroimaging five days after stroke, follow up imaging at three months revealed bilateral thalamic encephalomalacia (Figure 1), as well as small bilateral cerebellar infarcts. Neuropsychology was consulted six months post-stroke to evaluate persistent cognitive and emotional/behavioral symptoms.

RESULTS

(Test results in Table 1). Test results demonstrated average estimated premorbid functioning, amnesia (anterograde and retrograde) and executive dysfunction (including emotional lability, stimulus bound behaviors), which interfered with performances on processing speed and verbal fluency tasks. Attention, working memory, and core language/visuospatial skills were spared. These symptoms contributed to difficulty navigating/exacerbation of psychosocial stress and necessitated external support for daily functions. Neuropsychological evaluation data were used to identify strategies to optimize patient coping and reduce caregiver burnout. At 16-months post-stroke, persistent amnesia and reduced emotional lability were reported by her family.

CONCLUSIONS

This case highlights the presence and need to characterize cognitive and behavioral deficits following bilateral thalamic infarction. Additionally, this case demonstrates the role of neuropsychology in characterization of cognitive and neuropsychiatric sequelae, including identification of relevant interventions/recommendations to inform treatment planning.

The value of serum Lp-PLA2 combined with MPO in the diagnosis of cerebral infarction caused by large artery atherosclerosis

OBJECTIVE

To explore the value of serum lipoprotein-associated phospholipase A2（Lp-PLA2）combined with myeloperoxidase（MPO）for the diagnosis of large artery atherosclerosis(LAA) cerebral infarction.

METHODS

Baseline data were collected from patients with first-ever acute cerebral infarction, serum Lp-PLA2 and MPO levels were measured. The etiology of cerebral infarction was classified according to the Chinese Ischemic Stroke Subtype Classification Standard. The risk factors associated with LAA cerebral infarction were identified by univariate and multivariate regression analysis. The diagnostic value of serum Lp-PLA2 and MPO for LAA cerebral infarction was assessed by the area under the receiver-operating characteristic (ROC) curve.

RESULTS

Overall 368 patients were involved, 148 patients (40.22 %) were LAA. The serum La-PLA2 and MPO levels were higher in the LAA group than those in non-LAA group (23.06 ± 3.39 ng/mL versus 17.48 ± 3.26 ng/mL; 93.60 ± 9.58 ng/mL versus 75.98 ± 15.53 ng/mL; P < 0.001 for both). Multivariate analysis showed that elevated levels of serum Lp-PLA2 (OR 1.742, 95 %CI 1.499-2.025; P < 0.001) and MPO (OR 1.060, 95 % CI 1.026-1.096; P = 0.001) were the independent risk factors of LAA cerebral infarction. The area under curve of the serum Lp-PLA2 combined with MPO for the diagnosis of LAA cerebral infarction was 0.896 [0.866 ∼ 0.927] (P < 0.001).

CONCLUSION

Serum Lp-PLA2 combined with MPO could be valued as a predictor of acute cerebral infarction caused by large artery atherosclerosis.

Dysregulation of Serum UCA1 and Its Clinical Significance in Patients with Acute Cerebral Infarction

OBJECTIVE

To investigate the expression of lncRNA UCA1 in serum of patients with acute cerebral infarction (ACI) and its relationship with prognosis.

METHODS

The serum lncRNA UCA1 level in participants was detected, and the correlation between the neurological function score (NIHSS score) of ACI patients and lncRNA UCA1 expression was analyzed. Patients were followed up at 3 months after discharge and were divided into favorable and unfavorable prognostic groups according to the modified Rankin scale (mRs). The risk factors of ACI patients with poor prognosis were analyzed, and the predictive value of each index for ACI prognosis was evaluated by ROC curve.

RESULTS

The level of lncRNA UCA1 in ACI group was increased (P<0.001). ROC analysis showed that high lncRNA UCA1 expression had clinical significance for the diagnosis of ACI. Spearman correlation analysis revealed that NIHSS score was positively correlated with lncRNA UCA1 expression level in ACI group (r=0.6537, P<0.001). Hcy level and NIHSS score in poor prognosis group (n=63) were higher than those in good prognosis group (n=84), and lncRNA UCA1 level in serum in poor prognosis group was increased in comparison to good prognosis group (P<0.05). Logistic regression analysis investigated that admission NIHSS score, infarct size, and increased lncRNA UCA1 were the risk factors affecting the prognosis of ACI.

CONCLUSION

Serum lncRNA UCA1 is abnormally elevated in ACI patients, and the elevated lncRNA UCA1 not only shows high accuracy in the diagnosis of ACI, but also has a certain predictive value for poor prognosis of ACI.

A case of moyamoya disease diagnosed as cerebral infarction in the early postpregnancy period and surgically treated by bilateral revascularization after term delivery

We treated a 37-year-old Japanese woman with moyamoya disease who developed cerebral infarction in the early period after pregnancy and had undergone infertility treatment. After being adequately informed, including regarding the risk of stroke in the perinatal period and the option to prioritize the treatment of moyamoya disease even if the pregnancy was interrupted, the patient decided to continue the pregnancy and underwent surgical treatment after a full-term delivery by caesarean section. No new stroke was observed throughout the perinatal period or postoperative course. Since serious stroke during the perinatal period has also been reported in moyamoya disease, it is important to plan "tailored" treatment by sufficiently informing patients considering individual backgrounds and for multiple medical departments, including obstetrics, neurology, and neurosurgery departments, to carry out close outpatient follow-up in the perinatal period and carefully careful medication usage and radiological examinations.

Hyperacute synchronous cardiocerebral infarction in a patient with new-onset atrial fibrillation: a case of myocardial infarction with nonobstructive coronary arteries

Hyperacute synchronous cardiocerebral infarction (CCI) is an extremely rare condition with an incidence of 0.009%. In the acute stage of ischemic stroke, there is a high prevalence of ECG abnormalities. Prolonged QTc, atrial fibrillation (AF) and ECG changes indicative of ischemic heart disease, such as Q waves, ST depression, and T wave inversion, were the most prevalent changes. There are three types of simultaneous CCI: cardiac conditions that cause cerebral infarction, cerebral infarction caused by cardiac conditions, and (c) dysregulation of the brain-heart axis or cerebral infarction causing myocardial infarction. Herein, we present a case of hyperacute synchronous CCI in an elderly patient with new-onset AF and myocardial infarction with nonobstructive coronary arteries (MINOCA).

Effects of comprehensive care measures based on the HAPA model on self-care, neurotransmitters and clinical outcomes in cerebral infarction patients

OBJECTIVE

Cerebral infarction is induced by cerebral artery occlusion, resulting in ischemia, hypoxia, necrosis of brain cells in the corresponding blood supply area, and then dysfunction. Health action process approach (HAPA) model emphasizes the proposal and practice of health behavior as a whole and uses self-monitoring and encouraging ultimately developed health behavior. The present study explores the effects of comprehensive nursing measures of HAPA model on neurotransmitters, self-care ability and clinical outcomes of cerebral infarction patients.

PATIENTS AND METHODS

One hundred and ten patients with cerebral infarction diagnosed and treated in our hospital from July 2020 to February 2022 were included as the subjects. The subjects were randomly grouped as the control (55 patients) and the study group (55 patients) and received conventional nursing measures and additional comprehensive nursing measures of HAPA model, respectively. The patients were tested for changes in self-care ability, nerve damage [myelin basic protein (MBP), S100B, glial fibrillary acidic protein (GFAP), neuron-specific enolase (NSE)] and neurotransmitter indexes [acid-soluble protein (Asp), neuropeptide Y (NPY), substance P (SP), glutamate (Glu)], respectively. The patients were considered as the good prognosis group (47 cases) and poor prognosis group (63 cases) according to the prognosis after comprehensive care. The logistic regression model was used to analyze the risk factors affecting the poor prognosis of patients with cerebral infarction.

RESULTS

After nursing, China Stroke Scale (CSS) score, the Fugl Meyer Rating Scale (FMA) score and Barthel index were significantly higher in both groups than before nursing, and all indexes were significantly higher in the study group than in the control group (p< 0.05). The length of hospital stay was significantly shorter in the study group than in the control group (p< 0.05). Compared with before nursing, the health knowledge, self-care skills, self-responsibility and self-concept of two groups were strongly increased after nursing, and the study group had much higher indexes than the control group (p< 0.05). After nursing, the levels of MBP, S100B, GFAP, NSE, Asp, NPY, SP and Glu in both groups were largely decreased, and more significant decrease was found in the study group (p< 0.05). Age, body mass index (BMI), hypertension history, coronary heart disease history and National Institutes of Health Stroke Score (NIHSS) score after treatment were significantly different between the good and poor prognosis groups (p< 0.05). The prognosis of patients in the study group was 52.73%, which was significantly higher than 32.73% in the control group (p< 0.05). Age, hypertension history, and post-treatment NIHSS score were independent risk factors related to poor prognosis by logistic multiple regression analysis (p< 0.05).

CONCLUSIONS

Comprehensive care measures of HAPA model may be used with advantage to improve the self-care ability, reduce the degree of neurological damage, and improve neurological function in cerebral infarction patients. Age, hypertension history, and NIHSS score after treatment were all risk factors related to poor prognosis.

Epiglottic Cyst With Slurred Speech Misdiagnosed as Acute Cerebral Infarction: A Case Report

INTRODUCTION

Epiglottic cysts are cysts that occur under the mucosa of the epiglottis. Patients with severe cysts may have difficulty in breathing. Slurred speech usually occurs in cerebrovascular diseases, especially with slurred speech as the starting symptom.

CASE REPORT

We describe the case of a patient with slurred speech as the first symptom. The patient was a 53-year-old man with slurred speech as the first symptom, and he was initially considered to have an acute cerebral infarction. However, the results of the cranial magnetic resonance imaging examination did not support the diagnosis. The possibility of neck tumor recurrence was considered based on past medical history. The findings of a computed tomography examination of the neck suggested an epiglottic cyst. The effect of anti-inflammatory and surgical treatment was significant, and speech returned to normal.

CONCLUSION

This case emphasizes that neurologists need to be vigilant when dealing with patients with slurred speech, which may be one of the clinical manifestations of epiglottic cysts.

Artery of Percheron Occlusion in China: A Case Report and Chinese Literature Review

INTRODUCTION

The artery of Percheron (AOP) is a rare anatomical variant in which bilateral paramedian thalami are supplied by a single vascular branch arising from the P1 segment of the posterior cerebral artery. We present a case of AOP occlusion presenting as loss of consciousness and summarize the literature in Chinese to find the clinical characteristics.

CASE REPORT

An 83-year-old woman was found unconscious for 1 day at home and was sent to the hospital the next day. Cerebral magnetic resonance imaging on day 1 of the patient showed a recent bilateral paramedian thalamic infarction. Simultaneously, magnetic resonance angiography found evident artery stenosis of the right P1 segment of the posterior cerebral artery, suggesting that the patient was diagnosed with AOP occlusion. Since the patient has missed the best time for thrombolytic therapy, anticoagulant therapy was given immediately; as the patient was then found to have pulmonary infections, antibiotic therapy was also initiated. The neurological status of this patient improved very slow. In about 2 weeks, the patient becomes more conscious but still could not speak or move.

CONCLUSION

Our report suggests that unusual mood disorder and language disorder of aged patients might indicate the AOP occlusion, and cerebral imaging of magnetic resonance imaging (better with magnetic resonance angiography) should be performed to establish the diagnosis of AOP occlusion. The fast and accurate diagnosis of stroke because of AOP occlusion could best benefit the patients.

Artificial Intelligence-Enabled Electrocardiogram for Atrial Fibrillation Identifies Cognitive Decline Risk and Cerebral Infarcts

OBJECTIVE

To investigate whether artificial intelligence-enabled electrocardiogram (AI-ECG) assessment of atrial fibrillation (AF) risk predicts cognitive decline and cerebral infarcts.

PATIENTS AND METHODS

This population-based study included sinus-rhythm ECG participants seen from November 29, 2004 through July 13, 2020, and a subset with brain magnetic resonance imaging (MRI) (October 10, 2011, through November 2, 2017). The AI-ECG score of AF risk calculated for participants was 0-1. To determine the AI-ECG-AF relationship with baseline cognitive dysfunction, we compared linear mixed-effects models with global and domain-specific cognitive z-scores from longitudinal neuropsychological assessments. The AI-ECG-AF score was logit transformed and modeled with cubic splines. For the brain-MRI subset, logistic regression evaluated correlation of the AI-ECG-AF score and the high-threshold, dichotomized AI-ECG-AF score with infarcts.

RESULTS

Participants (N=3729; median age, 74.1 years) underwent cognitive analysis. Adjusting for age, sex, education, and APOE ɛ4-carrier status, the AI-ECG-AF score correlated with lower baseline and faster decline in global-cognitive z-scores (P=.009 and P=.01, respectively, non-linear-based spline-models tests) and attention z-scores (P<.001 and P=.01, respectively). Sinus-rhythm-ECG participants (n=1373) underwent MRI. As a continuous measure, the AI-ECG-AF score correlated with infarcts but not after age and sex adjustment (P=.52). For dichotomized analysis, an AI-ECG-AF score greater than 0.5 correlated with infarcts (OR, 4.61; 95% CI, 2.45-8.55; P<.001); even after age and sex adjustment (OR, 2.09; 95% CI, 1.06-4.07; P=.03).

CONCLUSION

The AI-ECG-AF score correlated with worse baseline cognition and gradual global cognition and attention decline. High AF probability by AI-ECG-AF score correlated with MRI cerebral infarcts. However, most infarcts observed in our cohort were subcortical, suggesting that AI-ECG not only predicts AF but also detects other non-AF cardiac disease markers and correlates with small vessel cerebrovascular disease and cognitive decline.

Retinal, Optic Nerve, and Cerebral Infarction in Odontogenic Lemierre Syndrome

ABSTRACT

A 61-year-old healthy woman developed congestive orbitopathy, and bilateral retinal, optic nerve, and cerebral infarctions after removal of a chipped molar tooth. Ophthalmoscopy disclosed multiple retinal arteriolar occlusions and pallid swelling of both optic discs. Imaging revealed ipsilateral masticator and pterygoid muscle abscesses, and thrombosis of the right internal jugular vein and sigmoid sinus, both cavernous sinuses and superior ophthalmic veins, and restricted diffusion of both optic nerves and corona radiata. Blood cultures were positive for Streptococcus anginosus. Despite aggressive medical and surgical treatment, the patient remained unresponsive and presumptively blind. This case is an example of a catastrophic form of odontogenic Lemierre syndrome. Blindness, attributable to venous hypertension and vasculitis, has been rarely reported. Early recognition and treatment are critical to avoid such dire consequences.

Serum levels of sLOX-1 and Lp-PLA2 can predict the prognosis of acute cerebral infarction with a high specificity

Soluble lectin-like oxidized low-density lipoprotein receptor-1 (sLOX-1) and lipoprotein-associated phospholipase A2 (Lp-PLA2) plays an important role in acute cerebral infarction (ACI), whereas its clinical value in predicting the prognosis is unclear. Thus, this study aimed to explore this issue. A total of 127 ACI patients were included in this prospective observational study. The concentrations of sLOX-1 and Lp-PLA2 in serum were measured and their relationship with a poor prognosis 90 days after the onset of ACI was analyzed. We found that patients with poor prognosis had higher mean serum levels of sLOX-1 and Lp-PLA2. The level of sLOX-1 and Lp-PLA2 could predict the functional outcome of ACI. At the optimal cut off value of sLOX-1 level (1257.92 ng/ml), the sensitivity and specificity for the poor functional outcome were 0.69 and 0.753, respectively, and the area under ROC curve (AUC) was 0.727. Similarly, the optimal value for Lp-PLA2 level was 160.9 ng/ml, at which the sensitivity and specificity were 0.643 and 0.835, respectively; and the AUC was 0.758. When the two biomarkers were used in combination, the AUC was 0.855, and the sensitivity and specificity were 0.643 and 0.976, respectively, indicating a significant improvement of the diagnostic specificity. The level of sLOX-1 or Lp-PLA2 could thus serve as useful biomarkers to predict the functional outcome of ACI. Combined use of both indicators is better than the use of either single indicator, and provides the highest specificity in predicting poor prognosis.

Intermittent pneumatic compression combined with rehabilitation training improves motor function deficits in patients with acute cerebral infarction

To investigate the effect of intermittent pneumatic compression (IPC) combined with rehabilitation training on patients with acute cerebral infarction and motor impairment, seventy-four patients with acute cerebral infarction and hemiplegia were randomly and equally divided into two groups, the control group and the IPC treatment group. The patients in the control group received conventional drug therapy and rehabilitation training, and the patients in the treatment group received the IPC treatment in addition to the treatment given in the control group. Motor function, the primary outcome, of the two groups was evaluated by Fugl-Meyer motor function scores. The Barthel index assessment scale was used to evaluate the ability to perform activities of daily living of the two groups, as a secondary outcome. All these indicators were collected and compared before treatment and at 7 days, 14 days, and 30 days after treatment. The incidence of adverse reactions associated with treatment was also recorded. At 7, 14, and 30 days after treatment, the Fugl-Meyer scores (27.16 ± 7.37, 33.41 ± 7.16 and 38.72 ± 7.65) and Barthel scores (47.16 ± 7.37, 52.41 ± 7.16, and 56.09 ± 8.32) of the treatment group were also significantly higher than those (23.65 ± 3.11, 26.13 ± 3.25, and 28.75 ± 5.92; 44.15 ± 3.11, 46.63 ± 3.25 and 47.75 ± 4.22) of the control group (all P < 0.05). With the extension of follow-up time, both scores were higher. There were no treatment-related adverse events in either of the two groups of patients during or after treatment. In conclusion, the IPC combined with rehabilitation training can effectively improve motor function deficits, the ability to perform activities of daily living, and quality of life for patients.

Seaweed Intake and Risk of Cardiovascular Disease: The Circulatory Risk in Communities Study (CIRCS)

AIM

Seaweed contains soluble dietary fibers, potassium, and flavonoids and was recently reported to be inversely associated with the risk of coronary heart disease and mortality from stroke. However, epidemiological evidence on this issue has remained scarce.

METHODS

At the baseline survey of four Japanese communities between 1984 and 2000, we enrolled 6,169 men and women aged 40-79 years who had no history of cardiovascular disease. We assessed their seaweed intake using the data from a 24 h dietary recall survey and categorized the intake into four groups (0, 1-5.5, 5.5-15, and ≥ 15 g/day). We used sex-specific Cox proportional hazards models to examine the association between seaweed intake and risk of cardiovascular disease (stroke, stroke subtypes, and coronary heart disease).

RESULTS

During the 130,248 person-year follow-up, 523 cases of cardiovascular disease occurred: 369 cases of stroke and 154 cases of coronary heart disease. Seaweed intake levels were inversely associated with the risk of total stroke and cerebral infarction among men but not among women. Adjustment for cardiovascular risk factors did not change the associations: the hazard ratios (95% confidence intervals; P for trend) for the highest versus lowest categories of seaweed intake were 0.63 (0.42-0.94; 0.01) for total stroke and 0.59 (0.36-0.97; 0.03) for cerebral infarction. No associations were observed between seaweed intake and risks of intraparenchymal hemorrhage, subarachnoid hemorrhage, or coronary heart disease among men or women.

CONCLUSIONS

We found an inverse association between seaweed intake and risk of total stroke, especially that from cerebral infarction, among Japanese men.

Therapeutic effect of Danhong injection on diabetic patients with cerebral infarction and its influence on vascular endothelial function and hemodynamics

To investigate the therapeutic effect of Danhong injection on diabetic patients with cerebral infarction and its influence on vascular endothelial function and hemodynamic level. A total of 100 diabetic patients with cerebral infarction admitted to our hospital from November 2019 to November 2020 were identified as the research subjects and randomly divided into a control group given routine treatment and a study group treated with Danhong injection, with 50 cases in each group. The efficiency of the two groups on vascular endothelial function, blood glucose level, National Institute of Health Stroke Scale (NIHSS) score, the incidence of adverse reactions, and hemodynamic indicators were compared. Most (98%) of patients in the study group displayed effective outcomes, which was significantly better than that in the control group. The study group outperformed the control study group in the vascular endothelial function, blood glucose level, NIHSS score and hemodynamic indicators (P<0.05). There was no significant difference in the incidence of adverse reactions between the two groups (P>0.05). Danhong injection obtains a promising therapeutic effect on diabetic patients with cerebral infarction, as it significantly improves the vascular endothelial function and hemodynamic level.

One Disease with two Faces: Semidominant Inheritance of a Novel HTRA1 Mutation in a Consanguineous Family

OBJECTIVES

To identify the underlying genetic defect for a consanguineous family with an unusually high number of members affected by cerebral small vessel disease.

MATERIALS AND METHODS

A total of 6 individuals, of whom 3 are severely affected, from the family were clinically and radiologically evaluated. SNP genotyping was performed in multiple members to demonstrate genome-wide runs-of-homozygosity. Coding variants in the most likely candidate gene, HTRA1 were explored by Sanger sequencing. Published HTRA1-related phenotypes were extensively reviewed to explore the effect of number of affected alleles on phenotypic expression.

RESULTS

Genome-wide homozygosity mapping identified a 3.2 Mbp stretch on chromosome 10q26.3 where HTRA1 gene is located. HTRA1 sequencing revealed an evolutionarily conserved novel homozygous c.824C>T (p.Pro275Leu) mutation, affecting the serine protease domain of HtrA1. Early-onset of cognitive and motor deterioration in homozygotes are in consensus with CARASIL. However, there was a clear phenotypic variability between homozygotes which includes alopecia, a suggested hallmark of CARASIL. All heterozygotes, presenting as CADASIL type 2, had spinal disk degeneration and several neuroimaging findings, including leukoencephalopathy and microhemorrhage despite a lack of severe clinical presentation.

CONCLUSION

Here, we clearly demonstrate that CARASIL and CADASIL type 2 are two clinical consequences of the same disorder with different severities thorough the evaluation of the largest collection of homozygotes and heterozygotes segregating in a family. Considering the semi-dominant inheritance of HTRA1-related phenotypes, genetic testing and clinical follow-up must be offered for all members of a family with HTRA1 mutations regardless of symptoms.

Predicting hemorrhagic transformation after large vessel occlusion stroke in the era of mechanical thrombectomy

Serum biomarkers are associated with hemorrhagic transformation and brain edema after cerebral infarction. However, whether serum biomarkers predict hemorrhagic transformation in large vessel occlusion stroke even after mechanical thrombectomy, which has become widely used, remains uncertain. In this prospective study, we enrolled patients with large vessel occlusion stroke in the anterior circulation. We analyzed 91 patients with serum samples obtained on admission. The levels of matrix metalloproteinase-9 (MMP-9), amyloid precursor protein (APP) 770, endothelin-1, S100B, and claudin-5 were measured. We examined the association between serum biomarkers and hemorrhagic transformation within one week. Fifty-four patients underwent mechanical thrombectomy, and 17 patients developed relevant hemorrhagic transformation (rHT, defined as hemorrhagic changes ≥ hemorrhagic infarction type 2). Neither MMP-9 (no rHT: 46 ± 48 vs. rHT: 15 ± 4 ng/mL, P = 0.30), APP770 (80 ± 31 vs. 85 ± 8 ng/mL, P = 0.53), endothelin-1 (7.0 ± 25.7 vs. 2.0 ± 2.1 pg/mL, P = 0.42), S100B (13 ± 42 vs. 12 ± 15 pg/mL, P = 0.97), nor claudin-5 (1.7 ± 2.3 vs. 1.9 ± 1.5 ng/mL, P = 0.68) levels on admission were associated with subsequent rHT. When limited to patients who underwent mechanical thrombectomy, the level of claudin-5 was higher in patients with rHT than in those without (1.2 ± 1.0 vs. 2.1 ± 1.7 ng/mL, P = 0.0181). APP770 levels were marginally higher in patients with a midline shift ≥ 5 mm than in those without (79 ± 29 vs. 97 ± 41 ng/mL, P = 0.084). The predictive role of serum biomarkers has to be reexamined in the mechanical thrombectomy era because some previously reported serum biomarkers may not predict hemorrhagic transformation, whereas the level of APP770 may be useful for predicting brain edema.

Diagnostic Utility of Polymerase Chain Reaction for Paraffin-embedded Sinus Specimens for Rhinocerebral Mucormycosis Complicated by Internal Carotid Artery Thrombosis and Cerebral Infarction

We herein report a 73-year-old man who experienced cerebral infarction caused by infection with a Mucromycocetes species. A delay in anti-fungal treatment might result in a lethal clinical outcome. We were unable to establish an accurate diagnosis based on histological findings and cerebrospinal fluid culture. Therefore, we performed polymerase chain reaction (PCR) using paraffin-embedded specimens, and based on the findings, successfully started administering anti-fungal treatment. We suggest that PCR using sinus specimens be applied when mucormycosis is suspected as an etiology of cerebral infarction and a confirmative diagnosis cannot be established based on the results of pathological examinations or cerebrospinal fluid culture.

Abnormal singing can identify patients with right hemisphere cortical strokes at risk for impaired prosody

Despite lacking aphasia seen with left hemisphere (LH) infarcts involving the middle cerebral artery territory, right hemisphere (RH) strokes can result in significant difficulties in affective prosody. These impairments may be more difficult to identify but lead to significant communication problems.We determine if evaluation of singing can accurately identify stroke patients with cortical RH infarcts at risk for prosodic impairment who may benefit from rehabilitation.A prospective cohort of 36 patients evaluated with acute ischemic stroke was recruited. Participants underwent an experimental battery evaluating their singing, prosody comprehension, and prosody production. Singing samples were rated by 2 independent reviewers as subjectively "normal" or "abnormal," and analyzed for properties of the fundamental frequency. Relationships between infarct location, singing, and prosody performance were evaluated using t tests and chi-squared analysis.Eighty percent of participants with LH cortical strokes were unable to successfully complete any of the tasks due to severe aphasia. For the remainder, singing ratings corresponded to stroke location for 68% of patients. RH cortical strokes demonstrated a lower mean fundamental frequency while singing than those with subcortical infarcts (176.8 vs 130.4, P = 0.02). They also made more errors on tasks of prosody comprehension (28.6 vs 16.0, P < 0.001) and production (40.4 vs 18.4, P < 0.001).Patients with RH cortical infarcts are more likely to exhibit impaired prosody comprehension and production and demonstrate the poor variation of tone when singing compared to patients with subcortical infarcts. A simple singing screen is able to successfully identify patients with cortical lesions and potential prosodic deficits.

Free-floating and spinning thrombus of the basilar artery: A case report

RATIONALE

Free-floating thrombi in the intracranial artery are rare. We report a case of a free-floating and spinning thrombus caused by turbulent flow distal to the basilar artery stenosis. We compare thrombus changes in a series of images according to time and describe the approach to treatment and thrombosis resolution.</abstract>.

PATIENT CONCERNS

A 55-year-old man presented to the emergency department on March 21, 2020, with left-sided weakness, bilateral limb ataxia, and a one-day history of dysarthria. Brain magnetic resonance imaging showed multifocal infarctions in the pons and cerebellum with severe basilar stenosis.

DIAGNOSES

Digital subtraction angiography showed severe focal stenosis. A relatively large oval-shaped mobile thrombus was observed spinning due to turbulent flow at the distal portion of the stenosis.

INTERVENTIONS

We administered a combination antithrombotic regimen of warfarin and clopidogrel for 50 days.

OUTCOMES

No thrombus was observed on the third follow-up digital subtraction angiography.

LESSONS

No previous study has directly observed a mobile thrombus in the intracranial artery using digital subtraction angiography. We used a combination antithrombotic strategy, which was effective after long-term, rather than short-term, use.

A case report of reversible posterior encephalopathy syndrome with intracranial hemorrhage in a child

INTRODUCTION

The objective is to analyze the clinical diagnosis and treatment of children with rescindable posterior encephalopathy syndrome (PRES) and intracranial hemorrhage (ICH) to improve the pediatrician's understanding of PRES combined with ICH in children.

PATIENT CONCERNS AND DIAGNOSIS

After liver transplantation, the patient developed symptoms of epilepsy and coma. Meanwhile, massive necrosis of acute cerebral infarction and small hemorrhage was observed in the left cerebellar hemisphere and left occipital lobe, respectively. The above symptoms were initially diagnosed as PRES.

INTERVENTIONS AND OUTCOMES

After adjusting the anti-rejection drug regimen, it was found that the child's neurological symptoms were relieved, and the limb motor function gradually recovered during follow-up. Imaging examination showed significant improvement on abnormal signals in brain.

CONCLUSION

In general, children with PRES may further develop ICH and contribute to a poor prognosis. Early diagnosis, detection of risk factors and timely adjustment of medication regimen are the keys to prevent irreversible brain damage.

Stroke Patients Without COVID-19 Symptoms: Is There a Need to Screen?

INTRODUCTION

COVID-19 patients who present with strokes but without typical COVID-19 symptoms have been described in small numbers. Despite the paucity of fever and respiratory symptoms, they remain capable of infecting others. The patient we discuss herein highlights the important issues of strokes as presenting events of COVID-19 infections, and how testing for COVID-19 in stroke patients, even when asymptomatic for COVID-19, can play an important role in infection control, clinical management and outcomes amidst this global pandemic.

CASE REPORT

A 45-year-old male resident of a dormitory presented to our unit with acute vertigo and left-sided dysmetria. NIHSS was 2. The initial magnetic resonance imaging demonstrated infarction of the left cerebellar hemisphere, middle cerebellar peduncle and hemipons. An extensive work-up for stroke etiologies was unremarkable. Despite having no fever, respiratory symptoms, anosmia or ageusia, he was isolated and screened for COVID-19 due to his epidemiologic risks, with multiple residents from his dormitory being recently diagnosed with COVID-19. Confirming our suspicion, his respiratory samples returned positive for COVID-19. His D-dimer levels returned normal. Thereafter, the patient underwent posterior decompression surgery due to worsening edema caused by the cerebellar infarct. He was started on antiplatelet therapy and recovered significantly a month from presentation with an modified Rankin Sore of 2. He remained without typical COVID-19 symptoms.

CONCLUSION

Our patient's case clearly supports the screening for COVID-19 in stroke patients who are without COVID-19 symptoms, appreciating the significant value it adds to infection control, clinical management, and outcomes amidst this global pandemic.

Simultaneous cardio-cerebral infarction in the coronavirus disease pandemic era: A case series

INTRODUCTION

Simultaneous occurrence of acute ischemic stroke and myocardial infarction is reported to have variable precipitating causes. This occurrence has been rarely reported in the literature and described only in very few case reports. During the surge of coronavirus disease (COVID-19) in our region, we noted an increase in the simultaneous occurrence of cardio-cerebral infarction. This led us to explore the possible mechanisms and pathophysiology that could contribute to this increase. The retrospective nature of the study limited us from drawing any conclusion about causation. Rather, we aimed to formulate a hypothesis for future, more rigorous studies.

PATIENT CONCERNS

We present an overview of 5 cases of simultaneous cardio-cerebral infarction that we encountered in our emergency department within 1 month.

DIAGNOSIS

In all cases, diagnosis was confirmed using an electrocardiogram, assessment of laboratory cardiac markers, and imaging.

INTERVENTIONS

In all cases, dual antiplatelet therapy was started and thrombolysis was held, as the condition was considered high risk in most of the patients. Cardiac catheterization lab was not activated either because the patient was unstable or the risk of COVID-19 in staff outweighed the benefit added in patient treatment.

OUTCOMES

Two out of 5 patients died because of early complications that lasted for few days. The remaining 3 were discharged from the hospital in moderate functionality for extensive therapy and rehabilitation.

CONCLUSION

Early recognition and immediate treatment is important in different scenarios leading to thrombosis as the outcome. Additionally, addressing the unknown risks that could contribute to our traditional understanding of these causative mechanisms is important. The hypothesis of exacerbated damage caused by inflammatory and immunological endothelial systemic damage should further be explored to be able to delineate new possibilities in managing these conditions.

Virtually All Complications of Active Infective Endocarditis Occurring in a Single Patient

Described herein is a 49-year-old black man with advanced polycystic renal disease, on hemodialysis for 6 years, who during his last 12 days of life had his vegetations on the aortic valve extend to the mitral and tricuspid valves, through the aortic wall to produce diffuse pericarditis, to the atrioventricular node to produce complete heart block, and embolize to cerebral arteries producing multiple brain infarcts, to a branch on the left circumflex coronary artery producing acute myocardial infarction, and to mesenteric arteries producing bowel infarction.

Clinical evidence and GRADE assessment for breviscapine injection (DengZhanHuaSu) in patients with acute cerebral infarction

ETHNOPHARMACOLOGICAL RELEVANCE

Breviscapine injections (DengZhanHuaSu, DZHS) is a famous Chinese patent medicine authorized by China Food and Drug Administration, which is widely used to treat acute cerebral infarction (ACI) in China.

AIM OF THE STUDY

In the present study, meta-analysis has been performed in determining the efficacy and safety of DZHS combined with conventional treatment (CT) for ACI and GRADE assessment.

MATERIALS AND METHODS

Randomized controlled trials (RCTs) testing the use of DZHS for treating ACI were screened by searching the databases of the Cochrane Library, PubMed, Embase, and Web of Science as well as four Chinese databases. Meta-analysis was carried out with RevMan 5.3 and Stata 16.0 software. The quality of research evidence was assessed by the GRADEprofiler (GRADEpro version: 3.6).

RESULTS

Forty-three studies (n = 4618) were included. When compared to the control groups, the total effective rate of the national institutes of health stroke scale (NIHSS) was higher in the experimental group with DZHS (RR = 1.23, 95% CI = 1.19 to 1.28, P < 0.001; RR = 1.29, 95% CI = 1.21 to 1.38, P < 0.001); clinical symptoms and signs were improved in the experimental group with DZHS (RR = 1.17, 95% CI = 1.10 to 1.24, P < 0.001; RR = 1.25, 95% CI = 1.11 to 1.42, P < 0.001); the incidence of adverse reactions was reduced in the experimental group with DZHS (RR = 0.50, 95% CI = 0.26 to 0.98, P = 0.044); and the NIHSS score was decreased in the experimental group with DZHS (WMD = -3.30, 95% CI = -3.86 to -2.73, P < 0.001).

CONCLUSIONS

DZHS combined with CT is conditionally recommended to improve the total effective rate of the NIHSS, clinical symptoms, and neurological deficits and reduce the incidence of adverse reactions, and no serious adverse reactions were noted. The GRADE assessment indicates that the overall certainty quality of evidence is low. Further large-scale, well-designed and high-quality RCTs are needed to confirm the positive results. PROSPERO registration No. CRD42019128856.

The values of AHCY and CBS promoter methylation on the diagnosis of cerebral infarction in Chinese Han population

BACKGROUND

The goal of our study is to investigate whether the methylation levels of AHCY and CBS promoters are related to the risk of cerebral infarction by detecting the methylation level of AHCY and CBS genes.

METHODS

We extracted peripheral venous blood from 152 patients with cerebral infarction and 152 gender- and age-matched healthy controls, and determined methylation levels of AHCY and CBS promoters using quantitative methylation-specific polymerase chain reaction. We used the percentage of methylation reference (PMR) to indicate gene methylation level.

RESULTS

We compared the promoter methylation levels of two genes (AHCY and CBS) in peripheral blood DNA between the cerebral infarction case group and the control group. Our study showed no significant difference in AHCY promoter methylation between case and control. Subgroup analysis by gender showed that the methylation level of AHCY in males in the case group was lower than that in the control group, but the difference was not statistically significant in females. In a subgroup analysis by age, there was no significant difference in the AHCY methylation level between the case and control in the young group (≤44 years old). However, the level of AHCY gene methylation in the middle-aged group (45-59 years old) was significantly higher and the aged group (≥60 years old) was significantly lower than that in the control groups. However, CBS promoter methylation levels were significantly lower in the case group than in the control group (median PMR: 70.20% vs 104.10%, P = 3.71E-10). In addition, the CBS methylation levels of males and females in the case group were significantly lower than those in the control group (male: 64.33% vs 105%, P = 2.667E-08; female: 78.05% vs 102.8%, P = 0.003). We also found that the CBS levels in the young (23-44), middle-aged (45-59), and older (60-90) groups were significantly lower than those in the control group (young group: 69.97% vs 114.71%; P = 0.015; middle-aged group: 56.04% vs 91.71%; P = 6.744E-06; older group: 81.6% vs 119.35%; P = 2.644E-04). Our ROC curve analysis of CBS hypomethylation showed an area under the curve of 0.713, a sensitivity of 67.4%, and a specificity of 74.0%.

CONCLUSION

Our study suggests that hypomethylation of the CBS promoter may be closely related to the risk of cerebral infarction and may be used as a non-invasive diagnostic biomarker for cerebral infarction.

Serum miR-133 as a Potential Biomarker in Acute Cerebral Infarction Patients

BACKGROUND

The study explores the expression and significance of miR-133 expression in peripheral blood of patients with acute cerebral infarction (ACI), so as to provide new evidence for the diagnosis and treatment of ACI.

METHODS

Serum levels of miR-133, interleukin-6 (IL-6), interleukin-8 (IL-8), C-reactive protein (CRP) and tumor necrosis factor-alpha (TNF-α) were examined using RT-PCR and ELISA, respectively. Pearson's correlation assay was used to analyze the relationship between the level of serum miR-133 and inflammatory factors. Kaplan-Meier method was used to analyze the 10-year survival rate of ACI patients with different levels of miR-133 expression.

RESULTS

The level of serum miR-133 in the ACI group was significantly higher than that in healthy group. Mean-while, the level of serum miR-133 in the large infarction group, middle infarction group, small infarction group, and lacunar infarction group was higher than in the healthy group. Moreover, the serum levels of miR-133 in patients with atherosclerotic thrombotic cerebral infarction (AT) and cardioembolic stroke (CE) were significantly higher than those in healthy subjects and small artery occlusive cerebral infarction (SAD) subjects. Serum levels of IL-6, IL-8, CRP and TNF-α in ACI group were significantly higher than those in healthy group. The correlation analysis showed that serum miR-133 was positively correlated with IL-6, IL-8, CRP, and TNF-α in ACI patients. The 10-year survival rate of the low-expression group was significantly higher than that of the high-expression group.

CONCLUSIONS

Serum level of miR-133 may indicate the onset and progression of cerebral infarction and may be a potential biomarker for the diagnosis of ACI.

Therapeutic effect of piracetam with nimodipine on vascular dementia after cerebral infarction

This article investigated the clinical effects of piracetam with nimodipine in the treatment of vascular dementia (VD) after cerebral infarction. 98 patients with vascular dementia after cerebral infarction were selected and divided into the control group and the study group according to the treatment method. The control group was treated with nimodipine alone. The study group was treated with piracetam on the basis of this observation, and we test the ADL (life ability score), MoCA(montreal cognitive assessment scale), ADAS-Cog(alzheimer's scale-cognition), MMSE(mental status examination) scores and quality of life scores before and after treatment in the two groups. Before treatment, there were no significant differences in ADL, MoCA, and ADAS-Cog scores between the two groups (P>0.05). After treatment, the ADL, MoCA, and ADAS-Cog scores of the study group were superior to the control group. The difference was statistically significant (P<0.05). There was no significant difference in MMSE scores between the two groups before treatment and 1 month after treatment (P>0.05). The MMSE scores of the study group were better than the control group after 3 months of treatment and half a year after treatment. The difference was statistically significant (P <0.05). Before treatment, there was no significant difference in the quality of life scores between the two groups (P>0.05). After treatment, the quality of life scores was significantly higher than the control group, and the difference was statistically significant (P<0.05). For patients with vascular dementia after cerebral infarction, piracetam combined with nimodipine can improve the cognitive function, improve the quality of life, and have a significant clinical effect.

Correlations of amide proton transfer-weighted MRI of cerebral infarction with clinico-radiological findings

Objective

To clarify the relationship between amide proton transfer-weighted (APTW) signal, which reflects intracellular pH, and clinico-radiological findings in patients with hyperacute to subacute cerebral infarction.

Materials and methods

Twenty-nine patients (median age, 70 years [IQR, 54 to 74]; 15 men) were retrospectively examined. The 10th, 25th, 50th, 75th, and 90th percentiles of APTW signal (APT₁₀, APT₂₅, APT₅₀, APT₇₅ and APT₉₀, respectively) were measured within the infarction region-of-interest (ROI), and compared between poor prognosis and good prognosis groups (modified Rankin Scale [mRS] score ≥2 and mRS score <2, respectively). Correlations between APTW signal and time after onset, lesion size, National Institutes of Health Stroke Scale (NIHSS) score, mRS score, and mean apparent diffusion coefficient (ADC) were evaluated.

Results

The poor prognosis group had lower APT₅₀, APT₇₅, and APT₉₀ than the good prognosis group (–0.66 [–1.19 to –0.27] vs. –0.09 [–0.62 to –0.21]; –0.27 [–0.63 to –0.01] vs. 0.31 [–0.15 to 1.06]; 0.06 [–0.21 to 0.34] vs. 0.93 [0.36 to 1.50] %; p <0.05, respectively). APT₅₀ was positively correlated with time after onset (r = 0.37, p = 0.0471) and negatively with lesion size (r = –0.39, p = 0.0388). APT₇₅ and APT₉₀ were negatively correlated with NIHSS (r = –0.41 and –0.43; p <0.05, respectively). APT₅₀, APT₇₅ and APT₉₀ were negatively correlated with mRS (r = –0.37, –0.52 and –0.57; p <0.05, respectively). APT₁₀ and APT₂₅ were positively correlated with mean ADC (r = 0.37 and 0.38; p <0.05, respectively).

Conclusion

We demonstrated correlations between APTW signals of infarctions and clinico-radiological findings in patients with hyperacute to subacute infarctions. The poor prognosis group had a lower APTW signal than the good prognosis group. APTW signal was reduced in large infarctions, infarctions with low ADC, and in patients with high NIHSS and mRS scores.

Different clinical courses of various radiologic findings in fibromuscular dysplasia during a 7-year follow-up: A case report

RATIONALES

The natural history of fibromuscular dysplasia (FMD) is unclear. Furthermore, the correlation between radiologic findings and clinical significance has not been documented. Previously, the development of new vascular symptoms was reported in a small number of patients, but some of these symptoms were from other vascular causes. New arterial lesions were rarely observed during follow-up in the previous reports.

PATIENT CONCERNS

A 40-year-old man was admitted due to dysarthria and left-sided weakness. He had developed flank pain due to bilateral renal infarction about 10 months earlier. He had no known risk factors for atherosclerosis. Initial neurological examination revealed a mild weakness and central facial palsy on the left side.

DIAGNOSES

Diffusion-weighted magnetic resonance imaging revealed a small acute infarction in the right insular cortex. Magnetic resonance angiography and digital subtraction angiography showed a severe stenosis with post-dilatation in the right internal carotid artery (ICA). There was a focal ectatic lesion in the left ICA. On the previous abdominal computed tomography angiography (CTA), there were arterial lesions suggestive of dissection in the bilateral renal arteries and a rod-shaped ectasia in the left common iliac artery (CIA). The pathological diagnosis was mixed-type FMD involving the intima and media.

INTERVENTIONS

The patient was prescribed antiplatelet agents for prevention of further ischemic events and followed up regularly.

OUTCOMES

Seven years after the initial renal infarction, the patient developed abdominal pain radiating to the back. Abdominal CTA revealed that an aortic dissection had developed in the infrarenal aorta, which was shown as normal previously. The ectasia in the left CIA and left ICA showed no interval changes during follow-up.

LESSONS

We present a patient who developed spontaneous symptomatic dissection of the bilateral renal arteries, right ICA, and abdominal aorta during 7 years of follow-up, which were caused by pathologically confirmed FMD. Besides the symptomatic multifocal dissection, the patient showed an asymptomatic multifocal ectasia on cerebral and abdominal angiographies that had not changed over 7 years.

Self-attention based recurrent convolutional neural network for disease prediction using healthcare data

BACKGROUND AND OBJECTIVE

Nowadays computer-aided disease diagnosis from medical data through deep learning methods has become a wide area of research. Existing works of analyzing clinical text data in the medical domain, which substantiate useful information related to patients with disease in large quantity, benefits early-stage disease diagnosis. However, benefits of analysis not achieved well when the traditional rule-based and classical machine learning methods used; which are unable to handle the unstructured clinical text and only a single method is not able to handle all challenges related to the analysis of the unstructured text, Moreover, the contribution of all words in clinical text is not the same in the prediction of disease. Therefore, there is a need to develop a neural model which solve the above clinical application problems, is an interesting topic which needs to be explored.

METHODS

Thus considering the above problems, first, this paper present self-attention based recurrent convolutional neural network (RCNN) model using real-life clinical text data collected from a hospital in Wuhan, China. This model automatically learns high-level semantic features from clinical text by using bi-direction recurrent connection within convolution. Second, to deal with other clinical text challenges, we combine the ability of RCNN with the self-attention mechanism. Thus, self-attention gets the focus of the model on essential convolve features which have effective meaning in the clinical text by calculating the probability of each convolve feature through softmax.

RESULTS

The proposed model is evaluated on real-life hospital dataset and used measurement metrics as Accuracy and recall. Experiment results exhibit that the proposed model reaches up to accuracy 95.71%, which is better than many existing methods for cerebral infarction disease.

CONCLUSIONS

This article presented the self-attention based RCNN model by combining the RCNN with self-attention mechanism for prediction of cerebral infarction disease. The obtained results show that the presented model better predict the cerebral infarction disease risk compared to many existing methods. The same model can also be used for the prediction of other disease risks.

Fibroblast Growth Factor 21 is Related to Atherosclerosis Independent of Nonalcoholic Fatty Liver Disease and Predicts Atherosclerotic Cardiovascular Events

Background FGF21 (fibroblast growth factor 21), a novel hepatokine regulating lipid metabolism, has been linked to atherosclerotic disease. However, whether this relationship exists in patients without nonalcoholic fatty liver disease is unclear. We assessed the association between serum FGF21 levels and atherosclerosis in patients without nonalcoholic fatty liver disease, and investigated whether baseline FGF21 could predict incident atherosclerotic cardiovascular disease in a 7-year prospective cohort. Methods and Results Baseline serum FGF21 was measured in a cross-sectional cohort of 371 patients with type 2 diabetes mellitus without nonalcoholic fatty liver disease (determined by hepatic magnetic resonance spectroscopy), and in a population-based prospective cohort of 705 patients from the Shanghai Diabetes Study. In the cross-sectional study, FGF21 was significantly higher in patients with than in those without subclinical carotid atherosclerosis (P<0.01). The association remained significant after adjusting for demographic and traditional cardiovascular risk factors. In the prospective cohort, 80 patients developed atherosclerotic cardiovascular disease during follow-up. Baseline FGF21 was significantly higher in those who developed ischemic heart disease or cerebral infarction than in those who did not. Using a cutoff serum concentration of 232.0 pg/mL, elevated baseline FGF21 independently predicted incident total atherosclerotic cardiovascular disease events, ischemic heart disease, and cerebral infarction in a nondiabetic population (all P<0.05), and significantly improved the discriminatory and reclassifying abilities of our prediction model after adjustment for established cardiovascular risk factors. Conclusions This study provides the first evidence that FGF21 levels are elevated in patients without nonalcoholic fatty liver disease with subclinical atherosclerosis. Baseline FGF21 is an independent predictor of atherosclerotic cardiovascular disease and represents a novel biomarker for primary prevention in the general population.

Bilateral basal ganglia infarcts presenting as rapid onset cognitive and behavioral disturbance

We describe a rare case of a patient with rapid onset, prominent cognitive and behavioral changes who presented to our rapidly progressive dementia program with symptoms ultimately attributed to bilateral basal ganglia infarcts involving the caudate heads. We review the longitudinal clinical presentation and neuropsychological testing for this patient, and discuss the implicated basal ganglia and frontal lobe neuroanatomy.

Comparison of Lymphocyte Count, Neutrophil to Lymphocyte Ratio and Platelet to Lymphocyte Ratio in Predicting the Severity and the Clinical Outcomes of Acute Cerebral Infarction Patients

BACKGROUND

To compare the prediction values of lymphocyte counts, neutrophil to lymphocyte ratio (NLR), and platelet to lymphocyte ratio (PLR) for the severity and the clinical outcomes of acute cerebral infarction (ACI).

METHODS

A total of 139 patients diagnosed with ACI were enrolled in this study. Data were gathered from medical records of patients who were admitted to the Fourth Affiliated Hospital Zhejiang University School of Medicine. Stroke severity was evaluated using the National Institutes of Health Stroke Scale (NIHSS). The clinical outcomes of ACI patients were evaluated using the Glasgow Outcome Scale (GOS) at day 30. Patients were classified into two groups based on their GOS at day 30. The Student's t-test of independent samples was adopted for the com-parison of the mean between two groups. The lymphocyte counts, NLR and PLR were evaluated by comparing the areas under the receiver operating characteristic curve (AUC) in predicting the clinical outcomes of ACI. The lin-ear correlations were specifically evaluated to determine the relationship between lymphocyte counts, NLR, PLR and the NIHSS score and the clinical outcomes of ACI. Comparison of AUC was performed using the Z-test.

RESULTS

The lymphocyte counts were significantly decreased in the poor outcomes group compared with the good outcomes group of ACI, while NLR and PLR were significantly increased (all p < 0.05); moreover, AUC in pre-dicting 30-day poor outcomes of ACI was 0.697 (95% confidence interval (CI), 0.614 to 0.772) for lymphocyte counts, 0.744 (95% CI, 0.663 to 0.814) for NLR, and 0.689 (95% CI, 0.605 to 0.764) for PLR, but there were no significant statistical differences (all p > 0.05). Finally, the lymphocyte counts were negatively correlated with the NIHSS score of ACI patients, while NLR and PLR were positively correlated (all p < 0.05); on the other hand, the lymphocyte counts were positively correlated with the GOS score of ACI patients, while NLR and PLR were nega-tively correlated (all p < 0.05).

CONCLUSIONS

As an inflammatory and immune biomarker, lymphocyte counts demonstrate similar test perfor-mance as NLR and PLR for predicting the severity and 30-day poor outcomes of ACI.

Acute Stroke in Tubercular Meningitis: A Case Report

Most of the strokes in tubercular meningitis are multiple, bilateral, and located in the basal ganglia, especially the ‘tubercular zone’, which comprises of the caudate, anterior thalamus, anterior limb, and genu of the internal capsule. These are attributed to the involvement of medial striate, thalamotuberal, and thalamostriate arteries, which are embedded in exudates and likely to be stretched by coexistent hydrocephalus. Corticosteroids with antitubercular therapy were thought to reduce mortality and morbidity but their role in lowering strokes has not been proven. The mechanism of stroke in our case was vasculitis. Here, we are reporting a case of 22-years female patient with tubercular meningitis. She had complications of ischemic infarct and severe communicating hydrocephalus with a seizure disorder.

Heart-Shaped Bilateral Medullary Pyramidal Infarction as a Pathognomonic Finding of Anterior Spinal Artery Occlusion

BACKGROUND

Unilateral anterior spinal artery (ASA) occlusion resulting in bilateral medullary pyramidal (BMP) infarction is a rare and devastating stroke subtype. We present two cases highlighting the diagnostic and clinical challenges of BMP infarction.

METHODS

Case reports and literature review.

RESULTS

A 57-year-old man rapidly had severe vomiting and diarrhea 2 h after a meal. Examination revealed bulbar weakness and areflexic tetraplegia. Respiratory failure developed, requiring intubation and mechanical ventilation. Brain magnetic resonance imaging (MRI) showed a heart-shaped region of diffusion abnormality, characteristic of BMP infarction. Cerebral angiography showed an occluded left vertebral artery with unilateral left-sided origin of ASA. The patient required tracheostomy and percutaneous gastrostomy tube and was discharged to rehabilitation, with little improvement of his tetraplegia at 3-month follow-up. A 43-year-old woman presented to the emergency department with acute onset of lower-extremity paresthesia and history of upper respiratory infection 2 weeks prior. Initial examination findings included bulbar weakness, dysphagia, hyporeflexia, and generalized weakness. After admission, she had severe respiratory distress and required intubation. Lumbar puncture was evaluated for Guillain-Barré syndrome, but cerebrospinal fluid protein concentration was normal. Changes on diffusion-weighted MRI of the brain showed the characteristic heart-shaped BMP infarction, indicating occlusion of a unilateral ASA. She required tracheostomy and percutaneous gastrostomy tube placement, with no paralysis resolution.

CONCLUSION

Acute BMP infarction may present with flaccid tetraplegia mimicking neuromuscular disorders. When the infarction is recognized early, intravenous thrombolysis can be considered to reduce morbidity of this rare stroke subtype.

Role of Paraoxonase 1 Activity and Oxidative/Antioxidative Stress Markers in Patients with Acute Cerebral Infarction

BACKGROUND

Paraoxonase1 (PON1) is an antioxidant which confers antioxidant properties to high-density lipoprotein (HDL) and prevents low-density lipoprotein (LDL) oxidation. The purpose of this study was to evaluate the activities of PON1 and oxidative/antioxidative stress markers in acute cerebral infarction.

METHODS

In this study, 161 patients diagnosed with acute cerebral infarction and 161 gender- and age-matched healthy controls were recruited. Based on the clinicoradiological profiles, the patients were further classified into two groups: lacunar infarction group and large-artery atherosclerosis group. We measured the individual lipid status parameters, oxidative and antioxidative stress status parameters, and PON1 activity.

RESULTS

Serum total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), and oxidative stress parameters in patients with acute cerebral infarction were significantly higher than those in the normal controls (p < 0.05). High-density lipoprotein cholesterol (HDL-C) level, PON1 activity, superoxide dismutase (SOD) activity, and antioxidative stress parameters in patients were lower than in the normal controls (p < 0.05). Superoxide anion (O2-), malondialdehyde (MDA), and PON1 levels in the lacunar infarction group were lower than in the large-artery atherosclerosis group (p < 0.05).

CONCLUSIONS

Oxidative stress markers and PON1 activity are sensitive indicators of acute cerebral infarction. Our findings suggest a severely impaired antioxidative protection mechanism in these patients. Our study provides new insights into the pathophysiological mechanisms of acute cerebral infarction, which may also provide new therapeutic targets for ischemic cerebrovascular diseases.

The Clinical Implications of Thrombelastography in the Diagnosis of Acute Cerebral Infarction

BACKGROUND

Thrombelastography (TEG) is an analyzer reflecting the dynamic changes of blood coagulation. It has been used as a diagnosis index in many diseases. The aim of this study was to evaluate the relationship between TEG and acute cerebral infarction.

METHODS

Eighty patients with acute cerebral infarction and 80 healthy controls were enrolled. Each patient's TEG results and routine coagulation indices were recorded. All analyses were conducted with SPSS16.0 software.

RESULTS

Patients with acute cerebral infarction showed lower TEG R and K levels but higher TEG MA levels. There was a significantly negative correlation between TEG R and fibrinogen in the patient group. In addition, receiver operator characteristic curve analysis showed that TEG MA (cutoff value 63.9 mm) was a predictor of acute cerebral infarction (AUC value = 0.741, sensitivity 61%, specificity 81%).

CONCLUSIONS

TEG results have important clinical implications in the early diagnosis of acute cerebral infarction.

Diagnostic Values of Neutrophil and Neutrophil to Lymphocyte Ratio in Distinguishing between Acute Cerebral Infarction and Vertigo

BACKGROUND

Vertigo and acute cerebral infarction (ACI) patients show similar symptoms such as dizziness and imbalance. This study was to investigate the diagnostic values of neutrophil counts and neutrophil to lymphocyte ratio (NLR) in distinguishing patients with ACI from those with vertigo.

METHODS

This retrospective study was performed and data were gathered from medical records of patients with vertigo symptoms from the Department of Emergency and Neurology Clinics who were admitted to the Fourth Affiliated Hospital Zhejiang University School of Medicine between August 2017 and January 2019. Of the 173 patients with vertigo symptoms, 111 non-ACI vertigo patients (vertigo group) and 62 cases diagnosed with ACI (ACI group) were enrolled in this study. The neutrophil counts, lymphocyte counts, platelet counts, NLR, and PLT to lymphocyte ratio (PLR) within 24 hours after admission were compared between the two groups. Student's t-test of independent samples was adopted for the comparison of the mean between two groups. The neutrophil counts and NLR were evaluated by comparing the areas under the receiver operating characteristic curve (AUC) in distinguishing patients with ACI from those with vertigo. Comparison of AUC was performed using the Z-test.

RESULTS

The neutrophil counts and NLR were significantly increased in the ACI group compared with the vertigo group (all p < 0.05), while there were no significant statistical differences of the lymphocyte counts, platelet counts, and PLR (all p > 0.05); moreover, AUC in distinguishing patients with ACI from those with vertigo was 0.647 (95% confidence interval (CI), 0.570 to 0.718) for neutrophil counts and 0.639 (95% CI, 0.562 to 0.710) for NLR, but there was no significant statistical difference (p > 0.05); finally, the cutoff values were 3.1 x 109/L in distinguishing patients with ACI from those with vertigo (specificity 41.44% and sensitivity 83.87%) for neutrophil counts and 2 (specificity 55.86% and sensitivity 67.74%) for NLR.

CONCLUSIONS

As easy-to-obtain inflammatory biomarkers, both neutrophil counts and NLR could demonstrate diagnostic values in distinguishing between ACI and vertigo.

Circulating miR-29b and miR-424 as Prognostic Markers in Patients with Acute Cerebral Infarction

BACKGROUND

Down-regulation of miR-29b and miR-424 have been observed in patients with acute cerebral infarction (ACI); however, the clinical significance of circulating miR-29b and miR-424 as prognostic markers still requires further investigation.

METHODS

A total of 45 patients diagnosed with ACI and 45 healthy volunteers were enrolled in this study, and the clinical information of the patients were collected. The serum samples of the participants were collected and stored at -80°C. The relative expression of miR-29b and miR-424 was determined using RT-qPCR, and the serum levels of IL-6, IL-4, TNF-α, and IFN-γ were measured using an enzyme-linked immunosorbent assay (ELISA) kits. The short-term prognosis of patients was evaluated using the Glasgow Outcome scale (GOS) at day 30.

RESULTS

The serum levels of miR-29b and miR-424 were significantly lower in patients with ACI compared with the healthy controls (p < 0.01) and the serum level of IL-6, IL-4, and TNF-α were significantly up-regulated in patients with ACI (p < 0.05); moreover, using the Glasgow Outcome scale (GOS) as a prognostic index, it has been proved that the serum level of both miR-29b and miR-424 were positively associated with the short-term prognosis of the patients; finally, the expression of the circulating miR-29b and miR-424 were negatively correlated with the serum level of IL-6, IL-4, and TNF-α.

CONCLUSIONS

Lower levels of circulating miR-29b and miR-424 in patients with acute cerebral infarction may predict poor prognosis, and the expression of circulating miR-29b and miR-424 are negatively correlated with the serum level of some pro-inflammatory cytokines, suggesting that circulating miR-29b and miR-424 may have the potential to become prognostic markers and therapeutic targets for the management of acute cerebral infarction.

Von Mises Strain as a Risk Marker for Vulnerability of Carotid Plaque: Preliminary Clinical Evaluation of Cerebral Infarction

Non-invasive assessment of carotid artery plaque vulnerability is a key issue for cerebrovascular disease. This study investigates Von Mises strain imaging in patients by relating Von Mises strain to cerebral infarction presentation. Ultrasonography was performed in patients evaluated for carotid artery stenosis. Strains were estimated by a flow-driven diffusion method and least-squares regression applying Kalman filtering. Von Mises strains ɛ_VM^sys and ɛ_VM^dia were calculated by averaging four or five cardiac cycles in systole and diastole, respectively. Von Mises strain (peak, coefficient of variance, skewness and kurtosis) in patients with cerebral infarction was compared with that in the control group. Higher Von Mises peak strain localized to echolucent areas on B-mode imaging. Higher peak strain was found in patients with cerebral infarction compared with the control group (p = 0.02 for ɛ_VM^dia and p = 0.001 for ɛ_VM^sys). The area under the receiver operating characteristic curve for peak ɛ_VM^sys was 0.761 (p = 0.001) with high sensitivity and specificity. Peak strain also correlated with homocysteine (r = 0.345, p = 0.007, for ɛ_VM^dia; r = 0.287, p = 0.036, for ɛ_VM^sys) and hypersensitive C-reactive protein (r = 0.399, p = 0.043, for ɛ_VM^dia; r = 0.195, p = 0.034, for ɛ_VM^sys) levels. The coefficient of variance, skewness and kurtosis of ɛ_VM^dia or ɛ_VM^sys were also associated with homocysteine levels. In conclusion, this study indicates that peak Von Mises strain is a potential clinical risk marker for carotid plaque vulnerability and cerebral infarction.