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The increasing availability of biomedical data has attracted the interest of many researchers to understand and perform analysis on extracted patterns from data. Stroke is considered as one of the main causes of deaths worldwide. A considerable amount of work has been performed related to the cause of stroke and other physiological effects. Cerebral emboli is considered as one of the main sources of stroke. Algorithms from one of the traditional subjects called signal processing have been used in cerebral emboli detection and lot of researchers have performed emboli detection and classification using Fourier transform based algorithms and different filtering approaches.In this paper, we discuss the physics of Doppler ultrasound and perform review of cerebral emboli detection algorithms and some animal models used in understanding the behaviour, size, and composition of emboli development. Ranging from Fourier transform, wavelet transform based emboli detection to neural network architectures trained with Doppler signal spectra, we performed comprehensive review of signal processing based cerebral emboli detection works and provide some basic understanding of related terms in emboli detection. With natural arterial structural relation between humans and some animals, we highlight some of the animal models used for understanding the nature of emboli development process.

Background: Pulmonary hypertension is a rare complication of sarcoidosis. The pathogenesis of sarcoidosis-related pulmonary hypertension is multifactorial, and patients with sarcoidosis-related pulmonary hypertension can have variable treatment responses and prognoses. While selexipag (Nippon Shinyaku / Kyoto / Japan) was recently approved in Japan for the treatment of pulmonary hypertension, the risk of cerebral infarction has not been clearly reported. Case report: A 63-year-old Asian female with a diagnosis of ocular and cutaneous sarcoidosis developed shortness of breath and was referred to our department to rule out cardiac sarcoidosis. Swan–Ganz catheterization was performed, and she was diagnosed with pulmonary arterial hypertension and started on selexipag. A few days after starting treatment, she presented with hemiplegia and was diagnosed with cardiogenic cerebral embolism by using magnetic resonance imaging. As there was no evidence of pre-existing intracardiac thrombosis, we suspected unusual cerebral embolism. Echocardiography revealed a deep venous thrombus and a bubble study revealed a right-left shunt through a patent foramen ovale. Conclusions: The initiation of selexipag improved pulmonary blood flow and caused cerebral embolism, which was an unusual and unexpected event. This report highlights the importance of confirming the presence of patent foramen ovale and a deep venous thrombus before starting treatment for pulmonary hypertension.

Background: It was previously reported, based on a retrospective study, that preliminary removal of air bubbles in heparinized saline water with extracorporeal balloon inflation reduced the incidence of asymptomatic cerebral embolism (ACE). The present study aims to compare the incidence of ACE between a conventional and pre-inflation method during cryoballoon ablation in a prospective randomized controlled study. Methods: A total of 98 atrial fibrillation patients were enrolled and randomized into conventional and pre-inflation groups. Patients in the pre-inflation group received balloon massaging with preliminary extracorporeal balloon inflation in saline water before the cryoballoon was inserted into the body. Results: The baseline characteristics were similar between the two groups. Post-procedural 3-Tesla MRI revealed CE in 27.6% of patients. Symptomatic CE only occurred in two patients in the pre-inflation group. One patient had transient dysarthria and mild muscle weakness in one hand; the other patient complained of transient left upper limb weakness, left lower limb paresthesia and dysarthria. The incidence of ACE detected by cerebral MRI did not differ between the two groups to a statistically significant extent (conventional vs. pre-inflation; 22.9% vs. 29.2%; P = 0.49). In the multivariable analysis, eGFR was independently associated with the presence of ACE (odds ratio 0.95; 95% confidence interval 0.907–0.995; P = 0.03). Conclusion: In this prospective randomized study, the preliminary removal of air bubbles in heparinized saline water with extracorporeal balloon inflation had no impact on the incidence of ACE.

Mitral annular calcification (MAC) has been considered a predisposition and an association of thrombo-embolic disease. Superimposed thrombus on MAC is under-appreciated as a potential cause of systemic thrombo-embolism. This report describes an elderly gentleman, who had recurrent cerebral embolism and in one of the episodes, a large mobile thrombus was detected on the ventricular surface of calcified mitral annulus. The thrombus disappeared after initiation of anti-coagulation.

Objective: The use of upper extremity (UE) access is an accepted and often implemented approach for fenestrated/branched endovascular aortic aneurysm repair (F-BEVAR). The advent of steerable sheaths has enabled the performance of F-BEVAR using a total transfemoral (TF) approach without UE access, potentially decreasing the risks of cerebral embolic events. The purpose of the present study was to assess the outcomes of F-BEVAR using UE vs TF access., Methods: Prospectively collected data from nine physician-sponsored investigational device exemption studies at U.S. centers were analyzed using a standardized database. All patients were treated for complex abdominal aortic aneurysms (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs) using industry-manufactured fenestrated and branched stent grafts between 2005 and 2020. The outcomes were compared between patients who had undergone UE vs total TF access. The primary composite outcome was stroke or transient ischemia attack (TIA) and 30-day or in-patient mortality during the perioperative period. The secondary outcomes included technical success, local access-related complications, and perioperative mortality., Results: Among 1681 patients (71% men; mean age, 73.43 ± 7.8 years) who had undergone F-BEVAR, 502 had had CAAAs (30%), 535 had had extent IV TAAAs (32%), and 644 had had extent I to III TAAAs (38%). UE access was used for 1103 patients (67%). The right side was used for 395 patients (24%) and the left side for 705 patients (42%). UE access was preferentially used for TAAAs (74% vs 47%; P < .001). In contrast, TF access was used more frequently for CAAAs (53% vs 26%; P < .01). A total of 38 perioperative cerebrovascular events (2.5%), including 32 strokes (1.9%) and 6 TIAs (0.4%), had occurred. Perioperative cerebrovascular events had occurred more frequently with UE access than with TF access (2.8% vs 1.2%; P = .036). An individual component analysis of the primary composite outcome revealed a trend for more frequent strokes (2.3% vs 1.2%; P = .13) and TIAs (0.54% vs 0%; P = .10) in the UE access group. On multivariable analysis, total TF access was associated with a 60% reduction in the frequency of perioperative cerebrovascular events (odds ratio, 0.39; P = .029). No significant differences were observed between UE and TF access in the technical success rate (96.5% vs 96.8%; P = .72), perioperative mortality (2.9% vs 2.6%; P = .72), or local access-related complications (6.5% vs 5.5%; P = .43)., Conclusions: In the present large, multicenter, retrospective analysis of prospectively collected data, a total TF approach for F-BEVAR was associated with a lower rate of perioperative cerebrovascular events compared with UE access. Although the cerebrovascular event rate was low with UE access, the TF approach offered a lower risk of stroke and TIA. UE access will continue to play a role for appropriately selected patients requiring more complex repairs with anatomy not amenable to the TF approach., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Embolic protection devices are commonly used to prevent cerebral embolism during carotid artery stenting (CAS). However, the PercuSurge Guardwire device, a distal balloon protection device, was discontinued in April 2021. We present a case of successful CAS using a new distal balloon protection system. The procedure, referred to as the jailbreak technique, was performed via transradial access., Methods: A 67-year-old man underwent CAS, using the jailbreak technique, for right carotid stenosis with a vulnerable plaque. 6-French (Fr) and 4-Fr Simmons guiding sheaths were delivered into the right common carotid artery via the right and left transradial access, respectively. Distal balloon protection was provided using a 2.6-Fr dual-lumen balloon microcatheter (Pinnacle Blue 20, Tokai Medical Products, Aichi, Japan) via the 4-Fr Simmons guiding sheath. A 4.2-Fr catheter was coaxially delivered proximal to the balloon and distal to the lesion., Results: After CAS was successfully performed via the 6-Fr Simmons guiding sheath, the Pinnacle Blue 20 was retrieved through the 4.2-Fr catheter without interfering with the distal stent flare and stent struts. Postprocedural neuroimaging revealed no evidence of ischemic stroke., Conclusions: The jailbreak technique allows distal balloon protection during transradial CAS. This is a useful treatment option for patients with carotid stenosis., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: Upper extremity (UE) access is frequently used for fenestrated-branched endovascular aortic aneurysm repair (F-BEVAR), particularly for complex repairs. Traditionally, left-side UE access has been used to avoid crossing the arch and the origin of the supra-aortic vessels, which could potentially result in cerebral embolization and an increased risk of perioperative cerebrovascular events. More recently, right UE has been more frequently used as it is more convenient and ergonomic. The purpose of this study was to assess the outcomes and cerebrovascular events after F-BEVAR with the use of right- vs left-side UE access., Methods: During an 8-year period, 453 patients (71% male) underwent F-BEVAR at a single institution. UE access was used in more complex repairs. Left UE access was favored in the past, whereas right UE access is currently the preferred UE access side. Brachial artery cutdown was used in all patients for the placement of a 12F sheath. Outcomes were compared between patients undergoing right vs left UE access. End points included cerebrovascular events, perioperative mortality, technical success, and local access-related complications., Results: UE access was used in 361 (80%) patients. The right side was used in 232 (64%) and the left side in 129 (36%) patients for the treatment of 88 (25%) juxtarenal, 135 (38%) suprarenal, and 137 (38%) thoracoabdominal aortic aneurysms. Most procedures were elective (94%). Technical success was achieved in 354 patients (98%). In-patient or 30-day mortality was 3.3%. Five (1%) perioperative strokes occurred in patients undergoing right UE access, of which three were ischemic and two were hemorrhagic. No transient ischemic attacks occurred perioperatively. Two hemorrhagic strokes were associated with permissive hypertension to prevent spinal cord ischemia. No perioperative strokes occurred in patients undergoing left UE access (P = .16). Overall, perioperative strokes occurred with similar frequency in patients undergoing UE (5, 1%) and femoral access only (1, 1%) (P = .99). Arm access-related complications occurred in 15 (5%) patients, 11 (4.8%) on the right side and 4 (6%) on the left side (P = .74)., Conclusions: Right UE access can be used for F-BEVAR with low morbidity and minimal risk of perioperative ischemic stroke or transient ischemic attacks. In general, UE access is not associated with an increased risk of perioperative stroke compared with femoral access only. Tight blood pressure control is, however, critical to avoid intracranial bleeding related to uncontrolled hypertension., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to compare procedure-related ipsilateral cerebral embolism with a conventional (Acculink, Abbott Vascular) versus a MicroNet-covered (CGuard, InspireMD) stent in carotid artery stenting (CAS)., Background: The MicroNet-covered stent may reduce periprocedural cerebral embolism in CAS, but level 1 evidence is lacking., Methods: A total of 100 consecutive patients were randomized 1:1 to filter-protected CAS using the Acculink or the CGuard device. The study was powered for its primary endpoint of at least 50% reduction in ipsilateral diffusion-weighted magnetic resonance imaging lesion average volume 48 hours postprocedure (blinded external core laboratory analysis)., Results: The baseline characteristics of the study groups were similar. Eighty-two (total volume = 18,212 mm 3 ) diffusion-weighted magnetic resonance imaging postprocedural cerebral lesions occurred in 26 Acculink-treated patients and 45 lesions (total volume = 3,930 mm 3 ; 78.4% reduction) in 25 CGuard-treated patients. New cerebral lesion average volume was 171 mm 3 vs 73 mm 3 (P = 0.017) per affected patient and 222 mm 3 vs 84 mm 3 (P = 0.038) per lesion (Acculink vs CGuard). In lesion-affected patients, the average sum of lesion volumes was 701 mm 3 vs 157 mm 3 (P = 0.007). The Acculink significantly increased the risk for multiple (≥5) cerebral lesions (relative risk: 7.8; 95% CI: 1.3-14.9; P = 0.021). At 30 days, new permanent (fluid-attenuated inversion recovery) lesion prevalence was 3:1 (P < 0.001), with total permanent lesion volume 7,474 mm 3 vs 574 mm 3 (92.3% reduction with the CGuard). There were 6 vs 0 new ipsilateral lesions (P = 0.030) and 2 versus 0 strokes., Conclusions: The MicroNet-covered stent significantly reduced periprocedural and abolished postprocedural cerebral embolism in relation to a conventional carotid stent. This is consistent with the MicroNet-covered stent's sustained embolism prevention, translating into cerebral protection not only during but also after CAS. The present findings may influence decision making in carotid revascularization. (The SIBERIA Trial [Acculink™ Versus CGuard™]; NCT03488199)., Competing Interests: Funding Support and Author Disclosures The present study was an investigator-initiated study supported by the E.N. Meshalkin National Medical Research Centre and Jagiellonian University Medical College (ZDS/007819). External analysis of blinded DW-MRI data and clinical data independent monitoring was supported by FLOW Research and Development. Dr Musialek is a proctor, an advisory board member, and a consultant for Abbott Vascular, InspireMD, and Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Valvular heart disease (VHD) is frequently associated with neurologic complications. Cerebral embolism is the most common, since thrombus formation results from the abnormalities in the valvular surfaces and the anatomic and physiologic changes associated with valve dysfunction, including atrial or ventricular enlargement, intracardiac thrombi, and cardiac dysrhythmias. Prosthetic heart valves, particularly mechanical valves, are very thrombogenic, which explains the high risk of thromboembolism and the need for long-term anticoagulation. Transcatheter aortic valve replacement (TAVR) has emerged as a nonoperative alternative to surgical aortic valve replacement for patients with intermediate or high surgical risk, and the procedure also has a risk of cerebral ischemia. In addition, anticoagulation, the mainstay of treatment to prevent cerebral embolism, has known potential for hemorrhagic complications. The emergence of new oral anticoagulants with similar effectiveness to warfarin and a better safety profile has facilitated the management of patients with atrial fibrillation. However, their application in patients with mechanical heart valves is still evolving. The prevention and management of these complications requires an understanding of their natural history to balance the risks posed by valvular heart disease, as well as the risks and benefits associated with the treatment., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Catheter manipulation in the left-sided heart is known as a risk for cerebral embolisms (CEs). However, anticoagulation therapy is terminated before catheter ablation (CA) of atrial fibrillation (AF) concerning adverse bleeding events. Little is known whether uninterrupted direct oral anticoagulants (DOACs) during perioperative period of CA could render the ablation procedure safer and reduce the incidence of CEs compared to interrupted DOACs. The aim of this study was to investigate the safety and usefulness of uninterrupted dabigatran during the periprocedural period for CA of AF., Methods: We included 333 patients with paroxysmal AF undergoing cryoballoon CA (CBA). They were prospectively divided into 2 groups based on whether DOACs were interrupted on the day of the CA (Group A, n=228) or dabigatran was not interrupted throughout perioperative period (Group B, n=105) in a non-randomized fashion. When the Group B patients had taken other DOACs rather than dabigatran before assignment, we changed those DOACs to dabigatran. Brain magnetic resonance imaging (MRI) was undertaken on the following day of the CA. Serious bleeding event cases were excluded from the study., Results: The baseline characteristics including the CHADs2 score did not exhibit any significant differences between the groups. The brain MRI revealed an acute CEs in 82 patients, and was significantly higher in Group A than B (29% vs. 13%, respectively, p<0.01). There were no significant differences regarding the bleeding events (7% vs. 4%, respectively, p=0.62)., Conclusion: Uninterrupted dabigatran therapy during the CBA of paroxysmal AF could significantly reduce the incidence of CEs., (Copyright © 2019 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

As new transcatheter mitral valve (MV) interventions continuously evolve, potential procedure-related adverse events demand careful investigation. The risk of cerebral embolic damage is ubiquitous in any left-sided structural heart intervention (and potentially linked to long-term neurocognitive sequelae); therefore, efforts to evaluate these aspects in the field of catheter-based MV procedures are justified. Given the peculiarities of MV anatomy, MV disease, and MV procedures, the lessons learned from other transcatheter heart interventions (i.e., transcatheter aortic valve replacement) cannot be directly translated to MV applications. Through a systematic assessment of available evidence, the authors present and discuss procedure- and patient-related factors potentially associated with cerebral embolic risk during catheter-based MV interventions. Given the paucity of available data in this field, future large, dedicated studies are needed to understand whether cerebral embolic injury represents a real clinical issue during MV procedures., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Asymptomatic cerebral embolism (ACE) is sometimes detected after cryoballoon ablation of atrial fibrillation. The removal of air bubbles from the cryoballoon before utilization may reduce the rate of ACE., Objective: This study aims to compare the incidence of ACE between a conventional and a novel balloon massaging method during cryoballoon ablation., Methods: Of 175 consecutive patients undergoing initial cryoballoon ablation of paroxysmal atrial fibrillation, 60 (34.3%) patients underwent novel balloon massaging with extracorporeal balloon inflation in saline water (group N) before the cryoballoon was inserted into the body. The remaining 115 (65.7%) patients underwent conventional balloon massaging in saline water while the balloon remained folded (group C). Of those, 86 propensity score-matched patients were included., Results: The baseline characteristics were similar between the 2 groups. In group N, even after balloon massaging in saline water was carefully performed, multiple air bubbles remained on the balloon surface when the cryoballoon was inflated in all cases. Postprocedural cerebral magnetic resonance imaging detected ACE in 14.0% of all patients. The incidence of ACE was significantly lower in group N than in group C (4.7% vs 23.3%; P = .01). According to multivariable analysis, the novel method was the sole factor associated with the presence of ACE (odds ratio 0.161; 95% confidence interval 0.033-0.736; P = .02)., Conclusion: Preliminary removal of air bubbles in heparinized saline water with extracorporeal balloon inflation reduced the incidence of ACE. Since conventional balloon massaging failed to remove air bubbles completely, this novel balloon massaging method should be recommended before cryoballoon utilization., (Copyright © 2017 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Digestive endoscopic procedures have become increasingly common diagnostic and therapeutic procedures in hospitals. Generally they are safe procedures and complications, though infrequent, can occur and are potentially lethal. As the number of procedures performed increases, the complications arising are likely to become more frequent, so it is advisable to bear this in mind when establishing early diagnosis and treatment. Cerebral air embolism is a rare complication after a digestive endoscopic procedure, although in the case of endoscopic retrograde cholangiopancreatography (ERCP), may be as high as 10%. In such cases there are usually local circumstances exist favoring the entry of air into the bloodstream, and in some cases it is the presence of a patent foramen ovale that favors the passage of air into the arterial system. The clinical signs and symptoms will depend on the speed and volume of the air infused and on the territory affected, and in some cases the consequences may be fatal., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Mitral annular calcification (MAC) has been considered a predisposition and an association of thrombo-embolic disease. Superimposed thrombus on MAC is under-appreciated as a potential cause of systemic thrombo-embolism. This report describes an elderly gentleman, who had recurrent cerebral embolism and in one of the episodes, a large mobile thrombus was detected on the ventricular surface of calcified mitral annulus. The thrombus disappeared after initiation of anti-coagulation., (Copyright © 2016 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.)

Background: To investigate the possible role of fluid mechanical factors in thromboembolism that occurs at a high rate in the human middle cerebral artery (MCA)., Methods: Isolated transparent cerebral arterial trees containing the terminal bifurcation of the internal carotid artery (ICA), where the ICA bifurcated into the MCA and the anterior cerebral artery, were prepared from human cadavers. The flow behavior and distribution of embolus-model polystyrene particles in dilute suspensions at the bifurcation were studied in detail by means of flow visualization and high-speed cinemicrographic techniques., Results: Large particles in suspensions flowing through the ICA migrated radially away from the vessel wall toward the axis of the ICA. It became more remarkable by increasing the flow rate in the ICA (Q0), flow rate ratio of Q1 to Q0 (MCA/ICA), and particle diameter. As a result, redistribution of particles flowing in the ICA occurred at the bifurcation. The particles >1 mm in diameter (≈1/4 of vessel diameter) selectively entered the MCA, even when the flow rate ratio of Q1 to Q0 was decreased to as low as 0.34. In contrast, the particles whose diameters were <0.3 mm (≈1/10 of vessel diameter) and that did not show radial migration entered the MCA at the same rate as the flow rate ratio of Q1 to Q0., Conclusions: Due to the flow-dependent migration of particles away from the vessel wall toward the axis of the ICA, large particles selectively enter the MCA to which the core flow of the ICA is generally directed. This might explain why the incidence of thromboembolism is higher in the MCA than in the anterior cerebral artery in humans., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The treatment of acute ischemic stroke (AIS) using thrombolysis with recombinant tissue-plasminogen activator (rtPA, alteplase) is limited by its narrow time window and the risk of hemorrhage. Recombinant plasminogen activator (rPA, reteplase) has been used clinically on coronary artery thrombosis and acute myocardial infarction. It is necessary to induce strokes experimentally as a means of validating the rPA timing on patients with AIS. However, current embolic models cannot mimic clinical situations well due to the embolus's composition of dried blood clots or artificial materials. In this paper, we used two novel rat thromboembolic models to determine the dosage-effect relationship and therapeutic time window of r-PA. Male rats were administered rPA or rtPA intravenously at 2-12h postischemia. Cerebral blood flow, behavioral outcomes and infarct volume within the same animal group were determined. Our results demonstrated that rPA (0.2 and 0.4mg/kg) or rtPA (0.2mg/kg) restored focal perfusion, reduced cerebral infarction, and improved behavioral outcomes at 2-4h postischemia. rPA but not rtPA significantly restored focal perfusion at 6h postischemia. However, delayed rPA-treatment neither decreased infarct volume nor improved the neurological disorder. Cerebral hemorrhage occurred at 6h postischemia detected by Evan's blue leakage and tissue hemoglobin content. Collectively, Thrombolysis with rPA may be beneficial in revascularization at an acceptable dosage of 0.2-0.4mg/kg within 6h after the cerebral infarct onset., (Copyright © 2016. Published by Elsevier Ltd.)

Stroke is a major cause of death and disability worldwide. However, treatment options to date are very limited. To meet the need for validating the novel therapeutic approaches and understanding the physiopathology of the ischemic brain injury, experimental stroke models were critical for preclinical research. However, commonly used embolic stroke models are reluctant to mimic the clinical situation and not suitable for thrombolytic timing studies. In this paper, we established a standard method for producing a rat embolic stroke model with autologous thrombus formed within the common carotid artery (CCA) by constant galvanic stimulation. Then the thrombus was shattered and channeled into the origin of the MCA and small (lacunar) artery. To identify the success of MCA occlusion, regional cerebral blood flow was monitored, neurological deficits and infarct volumes were measured at 2, 4 and 6h postischemia. This model developed a predictable infarct volume (38.37 ± 2.88%) and gradually reduced blood flow (20% of preischemic baselines) within the middle cerebral artery (MCA) territory. The thrombus occluded in the MCA was able to be lysed by a tissue-type plasminogen activator (t-PA) within 4h postischemia. The techniques presented in this paper would help investigators to overcome technical problems for stroke research., (Copyright © 2015. Published by Elsevier B.V.)

Background: Cardiac myxomas rarely occur in children or adolescents. In addition, it is even more rare for the adolescent patient to present with neurological symptoms only. Early diagnosis is difficult because the symptoms of left atrial myxoma are frequently nonspecific. If delayed or left undiagnosed, severe and fatal complications, such as systemic embolism, heart failure, and pulmonary hypertension, may occur., Case Report: A 13-year-old girl was admitted to our resuscitation room because of loss of consciousness for the preceding 2 h; she had a longstanding history of headache and dizziness for the previous 18 months. Repeated investigations at her local hospital did not reveal any abnormalities. During this admission, routine chest x-ray study found an abnormal bulge of a segment of the pulmonary artery and elevated cardiac enzymes. Emergency bedside echocardiography was performed and revealed a myxoma in the left atria. Subsequent computed tomography head revealed cardiogenic cerebral embolism. When her condition was stable, the patient was taken to the operating room, where a tumorectomy was performed successfully. The patient was then treated with oral anticoagulants and an uneventful recovery was made. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In order to avoid delayed diagnosis and treatment of its potentially fatal complications, it is important for the emergency clinician to have a high level of suspicion for a cardiac myxoma when attending to young patients that present with syncope. We therefore recommend that, as routine practice, bedside echocardiography to be carried in the emergency department for young patients that present with syncope., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Valvular heart disease (VHD) is frequently associated with neurologic complications; cerebral embolism is the most common of these since thrombus formation results from the abnormalities in the valvular surfaces or from the anatomic and physiologic changes associated with valve dysfunction, such as atrial or ventricular enlargement, intracardiac thrombi, and cardiac dysrhythmias. Prosthetic heart valves, particularly mechanical valves, are very thrombogenic, which explains the high risk of thromboembolism and the need for anticoagulation for the prevention of embolism. Infective endocarditis is a disease process with protean manifestations that include not only cerebral embolism but also intracranial hemorrhage, mycotic aneurysms, and systemic manifestations such as fever and encephalopathy. Other neurologic complications include nonbacterial thrombotic endocarditis, a process associated with systemic diseases such as cancer and systemic lupus erythematosus. For many of these conditions, anticoagulation is the mainstay of treatment to prevent cerebral embolism, therefore it is the potential complications of anticoagulation that can explain other neurologic complications in patients with VHD. The prevention and management of these complications requires an understanding of their natural history in order to balance the risks posed by valvular disease itself against the risks and benefits associated with treatment., (© 2014 Elsevier B.V. All rights reserved.)

Arterial or central venous vascular access is the cornerstone of invasive cardiac diagnosis, monitoring, and therapeutics. Although procedural safety has significantly improved with protocols perfected over decades of use, their prevalence renders even the uncommon neurologic complication clinically relevant. Serious peripheral nerve complications result from direct or indirect nerve injuries in the setting of a hematoma or compartment syndrome. Functional outcome is dependent upon prompt diagnosis and early treatment, so proceduralists should be aware of the relevant anatomy and early signs of nerve injury. Ischemic stroke is the most common central nervous system complication of diagnostic and therapeutic cardiac catheterization, and is presumed to be due to embolization of atherosclerotic plaque or thrombus dislodged during guiding catheter manipulation, platelet-fibrin thrombus that forms on the catheters, or air that appears during catheter flushing. Acute neurologic deterioration after thrombolysis for acute myocardial infarction should be presumed to be an intracranial hemorrhage until proven otherwise. The ideal angiography suite of the future is patientcentric and multipurpose, coordinating diagnostic and therapeutic strategies for multivascular disease, allowing for multispecialty collaboration, and, in the event of a neurologic complication of a cardiac procedure, facilitating the various treating physicians to converge efficiently upon the patient., (© 2014 Elsevier B.V. All rights reserved.)