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Stroke is a global medical and socio-economic problem and a great demand for alternative therapies, the leading one being stem cell (SC) therapy. Pathogenetic processes in ischemic stroke (II) trigger the mechanisms of necrotic and apoptotic death of neurons with the formation of the central infarct zone («core of ischemia») and the ischemic «penumbra» zone; the severity and reversibility of the injury directly depends on the duration of ischemia. In parallel with pathogenetic processes, endogenous neurogenesis occurs – the proliferation of neurogenic stem and progenitor cells (NSC/NPC) and their migration into the ischemic focus; however, most NSCs and newly formed neurons undergo apoptosis and recovery of lost functions does not occur. Significant efforts are being made to find ways to control neurogenesis, in particular through the transplantation of exogenous SCs. The main factors preventing the use of SCs in humans are moral, ethical, religious and legal aspects related to the source and method of obtaining cells, as well as possible immunocompromised complications due to incompatibility of donor cells with the recipient of the main histocompatibility complex antigens. The safest is the use of autologous SCs (the patient’s own cells), as it does not require the use of immunosuppressive protocols. Due to the relative safety and ease of production, the most common are multipotent mesenchymal stem cells (MSCs), namely MSCs of the bone marrow (BM). Numerous preclinical studies in experimental animals with modeled II, as well as clinical trials conducted over the past 15 years, have shown the safety and feasibility of transplantation of autologous MSCs in patients with severe neurological deficits after II. Two different approaches to the use of MSCs are discussed: neuroprotection in the acute phase and neurorestoration in the chronic phase II. Proposals are currently being developed for phase II/III clinical trials in acute and chronic stroke using BM MSCs, the results of which will form the basis for certified standardized II treatment protocols.

Worldwide, each year the quantity of stroke death equal to 5.5million people. In SouthEast Asia, the proposed value is equal to 500 thousand people. In Vietnam the situation of ischemic strokes is critical. It has leads to recently appeared and uncontrolled risk factors. The current work is devoted to the main risk factors of ischemic cerebrovascular accident. Investigating most important risk factors in ischemic stroke patients presented in Phu Tho Provincial General Hospital. A prospectively observational study. Under proposed research the application (Software SPSS 18.0 and STATA 10.0) had been initiated. TIA was seen at 13.0% of all cases and risk of progressing to severe or death in OR=5.2; 63.5% of all patients appeared with hypertension had the risk of being severe or death with OR 3.2. Pre-exist of heart diseases was available in 28.1% cases with OR=2.6 in the risk of getting worse or death. Hyperlipidemia rate was high, risk of deterioration with OR=2.6. Alcohol and tobacco addiction was found in 72.6% patients and risk of becoming death or worse 2.4 times higher than alcohol and smoke – free patients. Some risk factors had good predictive prognosis value in ischemic stroke. The hypertension, cigarettes and alcohol abuse had been detected as one of the riskiest of the progress cerebrovascular accident. Most of the patients had pre-history addiction and diseases that can be one the cause of the Ischemic Cerebrovascular Accident (ICA). The ICA is the most health problems in Vietnam that need more attention.ICA, ischemic cerebrovascular accident, AIS, acute ischemic, AHS, acute hemorrhagic, ICU, intensive care unit, WHO, world health organization, HTN, hypertension, TIA, transient ischemic attack, AF, atrial fibrillation, MI, myocardial infarction, DMC, dilated Myocardiopathy, MVP, mitral valve prolapse, MVS, mitral valve, HF, stenosis heart failure, risk factors analysis, ischemic stroke, haemorrhagic stroke, ischemic cerebrovascular accident, stroke risk factors, Phu Tho hospital

Stroke is a devastating morbidity associated with left ventricular assist device (LVAD) support. We report a comprehensive analysis of stroke subtypes in the ENDURANCE destination therapy (DT) and ENDURANCE Supplemental (DT2) trials.Patients in the combined HeartWare LVAD (HVAD) cohorts of the DT and DT2 trials were included. Neurologic events included ischemic stroke (ischemic cerebrovascular accident [ICVA]), hemorrhagic stroke (hemorrhagic cerebrovascular accident [HCVA]), and transient ischemic attack (TIA). Peri-operative strokes were defined as occurring within 2 weeks of the implant.A total of 604 patients received an HVAD in the DT (n = 296) and DT2 (n = 308) trials. Over 2 years, 178 (29.5%) had at least 1 cerebrovascular accident (CVA). Forty-four (7.3%) had HCVAs, 116 (19.2%) had ICVAs, and 44 (7.3%) had TIAs. Thirty (5.0%) had peri-operative stroke. In multivariable analysis, sub-therapeutic international normalized ratio (INR) values were independently associated with peri-operative stroke. Supra- and/or sub-therapeutic INR values, peripheral vascular disease, and presence of left ventricular thrombus were independently associated with ICVA. No aspirin and supra- and/or sub-therapeutic INR values were independently associated with TIA. No aspirin, supra- and/or sub-therapeutic INR values, and prior stroke and/or TIA were associated with HCVA. In further analysis, mean arterial pressure (MAP) was higher in the ICVA (86.8mm Hg, p = 0.002 4) and TIA (88.8mm Hg, p0.0001) groups, but not in HCVA, than in the No-CVA group (81.4mm Hg). Time in therapeutic range for INR was 65.3% for the No-CVA group, 62.9% (p = 0.59) for HCVA, 65.1% (p = 0.97) for ICVA, and 63.2% (p = 0.62) for TIA.Supra- and sub-therapeutic INR values at the time of CVA were associated with all stroke subtypes14 days post-implant. MAP was higher among those with ICVA and TIA but not with HCVA compared to without CVA. Our study demonstrates the challenges of anti-thrombotic therapy and blood pressure management in LVAD population.

Antiphospholipid syndrome (APS) is infrequent at pediatric age (3 %) and is characterized by venous or arterial thrombosis and/or spontaneous abortions. APS occurs either as a primary condition or in the setting of an underlying disease. This is a case of a 12-year-old girl with a right hemiparesis and acute disturbance in gait, in which an ischemic cerebrovascular accident (CVA) due to middle cerebral artery thrombosis associated with positive antiphospholipid antibodies is confirmed (anticardiolipin antibody, lupus anticoagulant and anti-β2-glycoprotein antibody), fulfilling the criteria for the diagnosis of antiphospholipid syndrome. After starting treatment accordingly, the patient evolves favorably. As this pathology is infrequent and of variable presentation, it requires a high sense of alert from the health team to avoid delays in diagnosis and treatment.

Repulsive guidance molecule a (RGMa) plays a vital role in the progression of numerous inflammatory diseases. However, whether it participates in atherosclerosis development is not known. Here, we explored the influence of RGMa in atherogenesis by investigating whether an association exists between functional polymorphisms in the RGMa promoter and cerebrovascular atherosclerosis burden (CAB) in Chinese Han patients diagnosed with acute ischemic cerebrovascular accident. To this end, we conducted a genetic association study on 201 patients with prior diagnoses of acute ischemic stroke or transient ischemic attack recruited from our hospital. After admission, we conducted three targeted single-nucleotide polymorphisms (SNPs) genotyping and evaluated CAB by computed tomography angiography. We used logistic regression modeling to analyze genetic associations. Functional polymorphism analysis indicated an independent association between the rs725458 T allele and increased CAB in patients with acute ischemic cerebrovascular accident [adjusted odds ratio (OR) = 1.66, 95% confidence interval (CI) = 1.01–2.74, P = 0.046]. In contrast, an association between the rs4778099 AA genotype and decreased CAB (adjusted OR = 0.10, 95% CI = 0.01–0.77, P = 0.027) was found. Our Gene Expression Omnibus analysis revealed lower RGMa levels in the atherosclerotic aortas and in the macrophages isolated from plaques than that in the normal aortas and macrophages from normal tissue, respectively. In conclusion, the relationship between RGMa and cerebrovascular atherosclerosis suggests that RGMa has a potential vasoprotective effect. The two identified functional SNPs (rs725458 and rs4778099) we identified in the RGMa promoter are associated with CAB in patients diagnosed with acute ischemic cerebrovascular accident. These findings offer a promising research direction for RGMa-related translational studies on atherosclerosis.

Background: Ischemic and hemorrhagic cerebrovascular accidents remain common among patients with centrifugal-flow left ventricular assist devices, despite improvements in survival and device longevity. We compared the incidence of neurologic adverse events (NAEs) associated with 2 contemporary centrifugal-flow left ventricular assist devices: the Abbott HeartMate3 (HM3) and the Medtronic HeartWare HVAD (HVAD). Methods: Using the Society of Thoracic Surgeons Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs), we collected data on adult patients who received a centrifugal-flow left ventricular assist device as a primary isolated implant between January 1, 2017, and September 30, 2019. Major NAEs were defined as transient ischemic attack, ischemic cerebrovascular accident, or hemorrhagic cerebrovascular accident. The association of HVAD with risk of NAE in the first year after implant was evaluated using propensity score matching to balance for preimplant risk factors. After matching, freedom from first major NAE in the HM3 and HVAD cohorts was compared with Kaplan-Meier curves. A secondary analysis using multivariable multiphase hazard models was used to identify predictors of NAE, which uses a data-driven parametric fit of the early declining and constant phase hazards and the associations of risk factor with either phase. Results: Of 6205 included patients, 3129 (50.4%) received the HM3 and 3076 (49.6%) received the HVAD. Median follow-up was 9 and 12 months (HM3 and HVAD, respectively). Patients receiving HVAD had more major NAEs (16.4% versus 6.4%, P P P P P Conclusions: HM3 is associated with lower hazard of major NAEs than is HVAD beyond the early postimplantation period and during the constant hazard phase. Defining the explanation for this observation will inform device selection for individual patients.

O grupo das doenças cerebrovasculares ocupa o segundo lugar no índice da taxa de mortalidade no Brasil, sendo que o acidente vascular cerebral isquêmico (AVCI) é a sua manifestação mais prevalente. O AVCI é uma condição de alta gravidade e com potencial de causar morte e incapacidade irreversível caso não seja tratado com a devida urgência, sendo de vital importância o diagnóstico precoce e início da terapia no menor intervalo de tempo possível. Este estudo epidemiológico foi feito com o intuito de informar informações relevantes e atualizadas acerca do AVCI no território brasileiro a fim de expor a importância de uma maior vigilância na população mais vulnerável com o objetivo de minimizar os piores desfechos desta doença.

Paroxysmal nocturnal hemoglobinuria can rarely present as cerebral ischemia and stroke due to arterial thrombosis. However, it should be considered in a young patient with bone marrow failure features, systemic thromboses, and hemolysis. The variants of paroxysmal nocturnal hemoglobinuria pose a diagnostic challenge and hence are important to recognize. We report a case of a 28-years-old female with Herlyn Werner Wunderlich Syndrome who presented with an ischemic cerebrovascular accident, pancytopenia, hemoglobinuria, and widespread abdominal thromboses suggestive of paroxysmal nocturnal hemoglobinuria. The patient was managed symptomatically and referred to a hematologist.

In order to better realize the early detection of carotid atherosclerosis, a model of bifurcated carotid artery is designed and built in this paper. The structure of bifurcated carotid artery was constructed in COMSOL finite element analysis software, including the blood flow, the arterial wall and the arterial occlusion. The study assumes that the blood flow is laminar, non-newton, viscous and compressible and the arterial wall is elastic. Parameters of blood vessel, blood flow and arterial occlusion were assigned to the materials of geometry for simulation. The velocity of blood flow and the pressure of the blocked area and bifurcation are analyzed in condition of the different sizes of vascular stenosis. The result showed that the increase of the arterial occlusion leads to an exponential increase of the pressure of the blocked area and bifurcation, which may lead to the imminent ischemic cerebrovascular accident.

Here we report a case of atypical thrombotic thrombocytopenic purpura that presented as an ischemic cerebrovascular accident. A 56-year-old man with multiple cardiovascular risk factors presented with sudden left-sided weakness, slurred speech, and left facial droop. He showed mild improvement when he was treated with thrombolytic therapy according to the hospital stroke protocol. Later in the course, he developed thrombocytopenia followed by schistocytes revealed by peripheral blood smear and other lab abnormalities. Thrombotic thrombocytopenic purpura (TTP) was suspected, and he was treated with total plasma exchange that improved his condition significantly. This case shows that TTP can have unusual and atypical presentations either with the first episode or upon relapse, making diagnosis extremely difficult. Because patients may not present the expected clinical findings, it is important to be aware of variant presentations. In the early stages of the disease, platelet aggregation and thrombus formation may not be widespread, and thrombocytopenia and microangiopathic hemolytic anemia may not be clinically evident. Patients can present soon after the onset of symptoms when the typical laboratory abnormalities may not have had ample time to manifest. Although most other similar cases in the literature had a previous typical presentation of the disease before an atypical presentation, our patient’s first presentation was atypical. An atypical presentation of disease in a patient with cardiovascular risk factors may therefore be extremely difficult to diagnose. We believe that TTP should be considered for any patient presenting with stroke and thrombocytopenia.

Objective: to provide evidence based clinical recommendations for the diagnosis and therapy of the acute stage of ischemic cerebrovascular accident in EsSalud. Materials and methods: a group for producing the guideline was conveyed, including specialized physicians and methodologists. The group prepared 8 clinical questions to be answered by the guideline. Systematic searches of previous reviews were performed, and – when it was deemed necessary – primary studies in Medline and the Cochrane Controlled Registry of Trials for 2018 were reviewed. Evidence was selected aiming to respond each one of the proposed clinical questions. Certainty of the evidence was determined using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. In periodic work sessions, the group used GRADE methodology for reviewing the evidence and generated recommendations, good clinical practice items, and designed flow charts for both diagnosis and therapy. Finally, the guide was approved with the decree N° 128-IETSI-ESSALUD-2019. Results: this clinical practice guideline focused in 8 clinical questions, which were divided into four topics: screening, diagnosis, therapy, support and rehabilitation. On the basis of these questions, 28 recommendations were formulated (8 strong and 20 conditional), 38 items for good clinical practice, 1 implementation note, and 2 flow charts. Conclusion: this paper summarizes both evidence based methodology and conclusions from a new clinical practice guide for diagnosis and therapy of the acute stage of a cerebrovascular accident in EsSalud.

A 9-year-old girl patient presented with left-sided weakness and joint contractures developing over a period of 18 months. She was known to be suffering from β-thalassemia major and was on regular blood transfusions. Eighteen months ago, she had suffered from an episode of ischemic cerebrovascular accident affecting the right side of her brain. Magnetic resonance angiogram revealed vaso-occlusive disease affecting mainly the anterior cerebral circulation, resembling Moyamoya disease. She was advised to carry out regular physiotherapy but her parents discontinued it, which resulted in the gradual development of joint contractures and muscle wasting.

Introduction At least 30% of cerebrovascular accident (CVA) survivors suffer from neuropsychiatric symptoms as a direct sequela of their stroke, with poor long-term outcomes due to underdiagnosis and undertreatment. A 2018 systematic review of 76 studies looking at psychotic symptoms following stroke found an increased prevalence in delusional disorders, schizophrenia-like diagnoses, and mood disorders with congruent psychotic features. Right hemispheric lesions accounted for approximately 80% of patients demonstrating subsequent psychotic symptoms in studies with identification of lesion location. Among the many issues arising in management of these patients in addition to behavioral stabilization is decision-making concern should the patient be deemed gravely disabled. In this report, we present a case of a 58-year-old male with psychosis and mood disturbances following right-hemispheric ischemic stroke, and the resulting ethical and legal discussions regarding conservatorship and decision-making capacity. Methods Case report: this is the case of a 58-year-old male with psychiatric history of posttraumatic stress disorder, methamphetamine use disorder, cannabis use disorder and medical history pertinent for hypertension, hyperlipidemia, coronary artery disease, and dilated ischemic cardiomyopathy who was hospitalized for subacute onset of altered mental status following ischemic cerebrovascular accident. Magnetic resonance imaging (MRI) two weeks following initial vascular event confirmed right hemispheric ischemic stroke with subsequent hemorrhagic conversion. Additionally, in the two weeks after the initial vascular event, the patient had begun to exhibit significant behavioral changes mostly notable for an increase in psychotic and labile mood symptoms not previously present at patient's baseline mental status. These included auditory hallucinations, disorganized thinking and behavior, avolition, hypersexuality, emotional lability, irritability, and distractibility that persisted over the course of the following six weeks. He did not have a history of a bipolar disorder or a psychotic disorder, and had recently completed rehabilitation of polysubstance use at the West LA Veterans Administration Domiciliary. Urine drug screen was negative. Patient was managed by neurosurgery and neurology, with psychiatry consultation-liaison team providing recommendations for behavioral management. Psychiatry advised an involuntary hold for grave disability owing to patient's ongoing psychotic symptoms following medical stabilization. Of pertinent concern was the degree of to which patient's behavioral symptoms were interfering with his decision-making. Throughout the course of his hospitalization, patient needed repeated encouragement to participate in assessment, vitals, labs, and med administration, all of which he would refuse on a regular basis without appropriate reason. Bioethics review of patient's case affirmed that he lacked capacity to make major decisions regarding his healthcare and that his girlfriend, who held no legal status with relation to the patient, could serve as medical surrogate. Patient's refusal of medical intervention necessitated psychiatry consultation team to file a petition for prolonged involuntary hold as well as court-ordered medication administration. The patient's psychosis was initially managed with increased doses of his home aripiprazole (30mg), which was later tapered and cross-titrated with risperidone (5mg) for management of his psychotic symptoms and impulse control. Following stabilization of acute medical concerns, patient was subsequently transferred to psychiatric unit for persistent psychosis and for continued psychotropic medication management as well as assessment of legal and social status. Results N/a, case report. See ‘Conclusion' for discussion of case outcome. Conclusions The patient's condition ultimately improved to the point of being able to participate in a capacity declaration, designate a durable power of attorney, and forego the need for probate conservatorship. He continues to be seen by psychiatry for ongoing management of his mood, posttraumatic stress disorder, and mild cognitive impairment stemming from vascular insult. Management of psychiatric and behavioral symptoms following stroke continues to be an important component of the post-cerebrovascular vascular accident treatment plan. In particular, contingency plans need to be anticipated preventively in patients who may have higher risk of considerable decompensation following cerebrovascular stroke. In this particular case, the patient carried several premorbid psychiatric, vascular, and social risk factors that converged into a challenging management scenario post-CVA. Continued assessment and stratification of patients with these types of risk factors should continue to be an essential component to management of the geriatric patient. Funding None.

Introduction Stroke is a devastating disease, causing significant mortality and long-term disability worldwide. Since the bulk of ischemic strokes is attributed to atherothrombosis, secondary prevention with antiplatelet agents is essential to decrease the recurrence of stroke. Aspirin, as well as clopidogrel monotherapy, has been shown to reduce the relative risk of recurrent stroke. However, concerns regarding the efficacy and safety of dual antiplatelet approach still exist. Stroke patients are particularly susceptible to bleeding complications, which might be due to advanced age and comorbidities. Our study assessed the risk of serious bleeding among adult patients on antiplatelet therapy for secondary prevention after stroke who were admitted to Mount Lebanon Hospital (MLH) between 2010 and 2015. It also studied the effect of the antiplatelet therapy, including dose and combination in increasing the risk of bleed. Methods A retrospective monocentric study included 454 patients who were admitted for ischemic cerebrovascular accident (CVA) between 2010 and 2015, and discharged on antiplatelet therapy for secondary prevention. Those patients’ records were followed to assess the percentage of patients who developed a major bleed after initiation of antiplatelet therapy. Results The risk of serious bleed was highest with aspirin 100 mg monotherapy and dual antiplatelet therapy (DAPT) (Aspirin 100 mg + Clopidogrel 75 mg). Bleeding risk was high during the first three months of therapy. However, the highest risk of bleed exists during the duration extending between three months and one year for both aspirin 100 mg monotherapy and DAPT. Moreover, there was an established relation between patients’ related factors and bleeding risk. Advanced age and smoking were found to contribute to increasing this risk. Conclusion Aspirin 100 mg monotherapy and DAPT are associated with the highest risk of bleeding. Although this exists regardless of the duration of antiplatelet therapy, it is highest during the duration extending between three months and one year post initiation of antiplatelet therapy.

Objective: Venous thromboembolism (VTE) is a serious multifactorial disorder. Patients with severe mental illness have a higher risk of developing the condition compared to the general population. Methods: We observed 10 cases of VTE in patients with mental illness who were treated with the antipsychotic drug olanzapine. The diagnosis of VTE was made at the University Hospital Hradec Kralove (UH HK) from 2004 to 2013. VTE was objectively determined by imaging techniques (duplex ultrasonography, CT angiography) and laboratory tests (D-dimer). The average age was 46 years. The clinical manifestation of VTE was deep vein thrombosis in nine cases, including one case of simultaneous pulmonary embolism and one case of a concurrent ischemic cerebrovascular accident (iCVA). None of our patients had a history of malignant disease, trauma, or surgery. Results: Apart from antipsychotic medication, all the patients had clinical or laboratory risk factors for VTE. The most frequent clinical risk factors were obesity (n = 7) and smoking (n = 6). The most frequent laboratory risk factors were increased levels of FVIII (n = 4), mild hyperhomocysteinemia (n = 3), and factor V Leiden mutation (n = 2). VTE developed within 3 months after antipsychotic drug initiation in three patients and within 6 months in three patients. Conclusion: Olanzapine can be considered a precipitating factor for VTE formation. When olanzapine is administered, we need to monitor for clinical signs and symptoms of VTE, especially when other risk factors are present.

Background: Stroke or cerebrovascular accident (CVA) is noted as the second cause of mortality, especially in the elderly population. Recent studies indicated that higher concentrations of uric acid are involved in various vascular diseases. The findings of previous investigations suggest that, elevated serum alkaline phosphatase (ALP) levels may have a pathophysiological character in the occurrence of atherosclerotic vascular disease (AVD) of the heart and brain. This study evaluated the association between serum uric acid (SUA) levels, serum lipid levels, serum alkaline phosphatase (ALP) levels, and changes in ischemic cerebrovascular accident patients.Methods: All patients with Ischemic cerebrovascular accident age >50 years were included based on their clinical, laboratory, and radiological findings (including computed tomography (CT)/magnetic resonance imaging (MRI)) those admitted in our hospital. As control group 200 healthy individuals matched for sex and age were recruited from the same demographic area.Result: Multiple logistic regression analysis findings proposed four components as significant predictors in ischemic cerebrovascular accident (serum uric acid, serum ALP, LDL and HDL. In this study, it was found, that patients with ischemic cerebrovascular accident had significant difference (p

Cardiopulmonary bypass, the extreme of non-obstetric surgery during pregnancy, presents unique challenges to minimize maternal and fetal risk. We present our experience with a woman who was diagnosed with a left atrial myxoma following an ischemic cerebrovascular accident. We discuss clinical management specific to cardiopulmonary bypass during pregnancy and delivery in the context of a multidisciplinary team approach. We recommend using intermittent Doppler ultrasound as a non-invasive real-time assessment of uteroplacental perfusion during non-obstetric surgery in pregnancy. Monitoring of perfusion facilitates active feedback for appropriate in utero resuscitation in these cases.

Background: Serum Albumin level is an important multifunctional protein in the blood for maintaining the normal permeability across vessel wall by osmotic gradient, in inhibiting platelet aggregation and in reducing blood viscosity. Serum albumin level as a novel parameter for predicting outcome and assessment of severity of coronary artery disease is established. Keeping in mind the scarcity of studies regarding albumin level in ischemic Cerebrovascular Accident (CVA), present study was undertaken to correlate serum albumin level with clinical outcome in acute ischemic stroke (AIS) patients.Methods: One hundred patients of diagnosed AIS were included in the study. Thorough clinical examination and risk factor profile assessment was done. Severity of stroke was assessed using National Institute of Health Stroke Scale (NIHSS) Score and then followed up to 1 week and 3 months post-admission with serum albumin level and assessment was done using modified Rankin Scale (mRS) score. Institutional ethics committee cleared the study.Results: In 100 patients with AIS, 58% were male and 42% were female. Mean age was 65±8.160. Motor weakness (85%) was the commonest presenting symptom. Around 75% of patients revealed infarction in middle cerebral artery (MCA) territory. Hypertension (HTN) (74%) was the most frequently associated comorbid condition. Patients with low serum albumin level at admission time were directly proportional to severity of stroke at presentation and poor clinical outcome. 1 week and 3 months follow up mean albumin level (g/dl) was 3.8±0.25 and 3.7±0.23 in patients with poor functional outcome respectively. Significant co-relation between mean serum albumin level and clinical outcome was observed.Conclusions: Serum albumin level is inversely correlated with severity of stroke at presentation and functional outcome in patients on follow up.

Introduction Acute internal carotid artery occlusion is a devastating form of ischemic accident with significant morbidity and possible mortality. The “threatened hemisphere” is allowed limited access to collateral circulation further worsening the ischemic burden and the overall prognosis. Methods We present the details of a case of a 38-year-old woman who suffered from an ischemic stroke. The clinical course of which showed a hemodynamic dependence to preserve her neurological function, prompting the use of the phosphodiesterase inhibitor milrinone to maintain her neurological function. Result This case represents the first case in the literature in which a medical therapy is used to salvage brain tissue in the site of acute symptomatic large vessel occlusion. This has spared the patient from a potential significant morbidity and even mortality if a revascularization procedure had been attempted. Conclusion This innovative use of milrinone, if applied in more captured patients with internal carotid occlusion or those with reversible hemodynamic failure, would improve our understanding of the ischemic thresholds and cerebral vascular reserves and would improve the clinical outcome of this significant ischemic insult.

Antiphospholipid syndrome (APS) is a multisystem autoimmune disorder characterized by arterial or venous thrombosis and pregnancy morbidity in the presence of antiphospholipid antibodies (aPL).1 It can be primary or secondary. Primary antiphospholipid syndrome occurs in the absence of any other related disease. Secondary antiphospholipid syndrome occurs with other autoimmune diseases, such as systemic lupus erythematosus. The presence of aPL can be demonstrated in one of three ways: the presence of anticardiolipin antibodies (aCL), β 2-glycoprotein I antibodies (GPI), or lupus anticoagulant antibodies (LA).1 To meet classification criteria for antiphospholipid syndrome, patients should have one clinical criterion, either vascular thrombosis (venous or arterial) or pregnancy morbidity (at least one fetal death or preterm delivery or three or more unexplained, consecutive, spontaneous pregnancy losses) and one laboratory criterion, the presence of aPL antibodies need to be seen twice and at least 12 weeks apart for confirmation. Neurological manifestations are common in APS and are attributed mainly to vascular thrombosis and aPL-induced neuronal tissue injury. The most common neurological presentation is an ischemic cerebrovascular accident (CVA) or transient ischemic attack (TIA). However, clinical presentations including cognitive dysfunction, headaches, seizures, and psychosis may be atypical in some cases, which makes diagnosis more difficult.2 In our case, a male patient initially presented with a neurocognitive disorder, dementia, cerebral atrophy, and seizure of unknown etiology. A diagnosis of APS was made after a brain biopsy revealed microinfarcts and intimal fibrosis and an aPL antibody test was positive.

In response to acute ischemic stroke, large numbers of bone marrow stem cells mobilize spontaneously in peripheral blood that home onto the site of ischemia activating the penumbra. But with chronicity, the numbers of mobilized cells decrease, reducing the degree and rate of recovery. Cellular therapy has been explored as a new avenue to restore the repair process in the chronic stage. A 67-year-old Indian male with a chronic right middle cerebral artery ischemic stroke had residual left hemiparesis despite standard management. Recovery was slow and partial resulting in dependence to carry out activities of daily living. Our aim was to enhance the speed of recovery process by providing an increased number of stem cells to the site of injury. We administered autologous bone marrow mononuclear cells intrathecally alongwith rehabilitation and regular follow up. The striking fact was that the hand functions, which are the most challenging deficits, showed significant recovery. Functional Independence Measure scores and quality of life improved. This could be attributed to the neural tissue restoration. We hypothesize that cell therapy may be safe, novel and appealing treatment for chronic ischemic stroke. Further controlled trials are indicated to advance the concept of Neurorestoration.

Few vascular dementias are diagnosed in memory clinic consultations. One type, a rare etiology, Sneddon syndrome, can lead patients to consult for an isolated memory complaint. We report the cases of two patients, aged 63 and 66 years, who presented frontocortical cognitive profile and behavior disorders. Seronegative Sneddon syndrome, complicated with dementia, was diagnosed in each case by noticing an association between, on MRI, an atrophy and several ischemic cerebrovascular accident aftermaths, and a livedo racemosa. Management of vascular risks factors improves the prognosis.

Menorrhagia is a common symptom in women at the end of their fertility lifespan, with leiomyomas being the most common cause. Although current treatment options for premenopausal menorrhagia consis...

L’accident vasculaire cérébral (AVC) se définit comme le développement rapide de signes cliniques localisés ou globaux de dysfonction cérébrale sans autre cause apparente qu’une origine vasculaire. Différents facteurs de risque ont été identifiés et associés à la survenue des AVC ischémiques dont les perturbations du métabolisme glucidique et lipidique. Nous avons mené une étude rétrospective à la clinique neurologique de Fann. Notre étude a porté sur les dossiers des patients hospitalisés du 1er Janvier au 31 Décembre 2010 pour un AVCI confirmé par l’imagérie. Tous nos patients avaient beneficié d’un bilan lipidique complet (cholestérol total, triglycérides, HDL ; le taux de LDL ayant été calculé grâce à la formule de Friedwald, d’un bilan rénal et d’une glycémie à jeun prélevés dans les 48 heures suivant l’admission. Les données ont été analysées en mesure univariée, ensuite bivariée grace au logiciel SPSS 16.0. Nous avons colligé 235 dossiers. Les patients étaient âgés de 10 à 99 ans avec une moyenne à 67,06 ans. Le sexe masculin était à 42,55% , le sex-ratio était de 0,74 en faveur des femmes. Vingt Six pour cent avaient une glycémie à jeun anormale à la phase aiguë de l’AVCI. Le bilan lipidique montrait une augmentation du cholestérol total chez 52,34% des patients. Le HDL était bas chez 34,47% des patients . L’hypertriglycéridémie n’avait été observée que chez 3% des patients. Le LDL était élevé chez 12,76% . L’indice d’athérogénicité était élevé chez 25,53% des patients. Des perturbations de la glycémie et du bilan lipidique sont très souvent associées à l’AVCI et doivent être prises en compte pour assurer une meilleure prévention secondaire.The Pan African Medical Journal 2016;25

In brief: This case report describes a 32-year-old bodybuilder who sustained an ischemic cerebrovascular accident and showed signs of cardiomyopathy. No cause was found for either condition, but he had been using steroids for 16 years. Questions remain about the association between the two conditions and steroid use, and the full effects of long-term, high-dose steroid use have yet to be elucidated. As steroid use becomes more popular among athletes, the medical community must be alert to the possible adverse effects of these substances.

Objective The purpose of this study was to examine the usefulness of an emergency medical service (EMS)-requested air medical helicopter response directly to the scene for a patient with clinical evidence of an ischemic cerebrovascular accident (CVA) and transport to a regional comprehensive CVA center. Methods CareFlight, an air medical critical care transportation service, is based in Dayton, OH. The 3 CareFlight helicopters are geographically located and provided transport to all CVA scene patients in this study. A retrospective chart review was completed for all CareFlight CVA scene flights for 5 years (2011-2015). A total of 136 adult patients were transported. EMS criteria included CVA symptom presence for less than 3 hours or awoke abnormal, nonhypoglycemia, and a significantly positive Cincinnati Prehospital Stroke Scale. Results The majority of patients (75%) met all 3 EMS CVA scene criteria; 27.5% of these patients received peripheral tissue plasminogen activator, and 9.8% underwent a neurointerventional procedure. Conclusion Using a 3-step EMS triage for acute CVA, air medical transport from the scene to a comprehensive stroke center allowed for the timely administration of tissue plasminogen activator and/or a neurointerventional procedure in a substantive percentage of patients. Further investigation into air medical scene response for acute stroke is warranted.

Left atrial myxomas are rare primary cardiac tumors. Their incidence is estimated to be about 0.1% of total cases. Neurological complications resulting from cardiac myxomas are seen in 20–35% of patients. Transesophageal echocardiogram (TEE) is preferred over transthoracic echocardiogram for evaluation of left atrial myxoma. Three-dimensional (3D) echocardiography ensures better visualization of intracardiac structures. It has been used prior to surgery for diagnostic support in the surgical treatment of cardiac masses. We present a case of a 46-year-old Hispanic male who developed acute ischemic stroke of left frontal lobe and was also found to have multiple ‘silent’ cerebral infarcts in the MRI of the brain. On further workup, he was found to have a left atrial myxoma on 3D TEE. This was resected with the assistance of intra-operative 3D TEE imaging. We present this case to increase awareness and to stress at early evaluation of secondary causes of ischemic cerebrovascular accident, outside the realm of hypercoagulability. This case also exhibits the need for basic cardiac workup in young individuals who present with symptoms of intermittent palpitations or chest pain to minimize significant morbidity or mortality.Keywords: left atrial myxoma; three-dimensional transesophageal echocardiogram; acute stroke(Published: 17 February 2016)Citation: Journal of Community Hospital Internal Medicine Perspectives 2016, 6: 29604 - http://dx.doi.org/10.3402/jchimp.v6.29604

An adult greyhound was evaluated on three occasions for acute, intracranial neurologic signs. Based on magnetic resonance (MR) imaging, there were T2-hyperintense and T1-hypointense, noncontrast enhancing lesions in the cerebellum, and brain stem. Using diffusion-weighted imaging (DWI), the lesions were characterized initially by restricted water diffusion. The presumptive diagnosis on each occasion was acute ischemic cerebrovascular accident leading to infarction. This allowed us to characterize the changes in appearance of infarcted neural tissue on the standard MR sequences over time, and to confirm that the DWI could be successfully used in low-field imaging. © 2012 Veterinary Radiology & Ultrasound.

Honey bee stings usually won’t require hospitalization. The clinical features of Bee stings can be from local reactions such as pain, wheal, flare, edema, swelling to systemic anaphylactic reactions and infrequent major complications reported from different studies include rhabdomyolysis, acute renal failure, acute pulmonary edema, disseminated intravascular coagulation, stroke, encephalopathy and very rarely cerebral hemorrhage. (1,2) Stroke following bee sting can be due to toxins itself, following anaphylactic shock or pain induced catecholamines surge. Here we report a case on ischemic Cerebrovascular accident following multiple Bee stings complicated with anaphylactic shock.

Background: Renal impairment is one of the most frequent but anticipated potential complications. The objective of this meta-analysis was to evaluate the renal impairment following ischemic cerebrovascular accident (CVA) patients worldwide.Methods: Authors were using meta-analysis. Studies were obtained from several databases like Pubmed, Cochrane, Karger and JNS. Keywords were "renal" or "kidney" and "stroke" and "ischemic". Included studies were full-text observational study or randomized control trial (RCT). Subjects in study were newly diagnosed acute kidney disease (AKI) after ischemic CVA, with age range 18-100 years old. From 425 studies, total 5 studies were eligible for this study.Results: From those 5 studies, it is shown that the pooled risk ratio (RR) for mortality ischemic CVA with AKI was 2.56. AKI appeared insignificantly in both ischemic CVA and intracerebral haemorrhage (ICH) (RR 0.75; p=0.01). The pooled risk ratio had wide heterogeneity (I2 = 0.95) so random effect model was used.Conclusions: Renal impairment and its mortality appeared more frequent in ischemic CVA with AKI. It still needs more multicentre and long-term period researches in the future to get better understanding AKI in ischemic CVA.

Introduction In the United States, cerebrovascular accidents (CVAs) are the fourth most common cause of death with a general prevalence of 2.6%. Approximately 85% of all CVAs are of the ischemic type. Somatosensory evoked potentials (SSEPs) evoked through transcutaneous bipolar electrical stimulation applied to the selected nerve, this is one of the most informative neurophysiological techniques available, since it provides an evaluation of brain function. In turn, the middle latency somatosensory evoked potentials (MLSEP) between 35 and 100 ms after stimulation of the median nerve. SSEPs are abnormal in patients with lesions in the brainstem, diencephalon or cerebral hemispheres, when lemniscal pathways are involved, with similar patterns for brainstem, thalamic and thalamic-capsular lesions. The SSEPs have been studied in an attempt to prove their usefulness as a tool for clinical evaluation and prognosis in ischemic CVA. Methods Observational, cross-sectional, exploratory study enrolled 7 adult patients with corroborated ischemic stroke by imaging study (computed tomography CT or magnetic resonance imaging MRI) within the first 24 h of evolution. Short and middle latency somatosensory evoked potentials were performed at the American British Cowdray Medical Center, with Sierra Wave 4 channels electromyograph, recording and quantifying its latencies of N35, P45 and N60 ipsi and contralateral responses to the site of injury taking into account clinical and paraclinical variables. Results In this study 7 patients were recorded; the group had a median age of 61 years, with a minimum age of 25 years and maximum of 84 years. With their respective controls, the study showed the MLSEP in patients with CVA being of cardioembolic, atherothrombotic, prothrombotic and indeterminate etiology; in the short latency potentials peripheral response was found in all cases (N9), N60 was absent in patients with CVAs of different etiologies, the proportion of waves absent in lesion-ipsilateral MLSEP was greater than in contralateral MLSEP. Conclusion The clinical use of the middle latency responses has been limited by the incomplete knowledge of their generators, since the specific utility of this neurophysiological study is based on the evaluation of neurological pathways which can be interrupted in their journey by other pathologies such as ischemic stroke. The use of MLSEP shows that in patients with CVA they are present unilaterally, contralaterally and bilaterally, so the usefulness of performing them has future implications to determine the frequency of each of them related to the type of etiology, treatment and prognostic outcome.

We report a case of temporal lobe granuloma caused by Candida albicans in an immunocompetent patient. This 54-year-old patient had experienced headaches and some memory disorders for two to three months before his admission to the neurosurgical department. Cerebral-computer tomography and magnetic resonance imaging showed a single right-temporal lesion with a large peritumoral edema. We operated on the patient via a temporal approach using neuronavigation and resected the lesion. The anatomopathological result and the cultures of the granuloma showed C. albicans species. The patient received antifungal therapy for three months. No predisposing factors or immunosuppression was found. After seven months, he presented an ischemic cerebrovascular accident of the brain stem and then chronic meningitis complicated by hydrocephalus. The patient's condition progressively deteriorated and he died 18 months later in an other department. C. albicans can be found even in the immunocompetent patient, but is seldom observed. Surgery can provide an accurate diagnosis and therapeutic management in the initial phase, completed by antifungal therapy.

Ten patients with ischaemic cerebrovascular accident were given pentoxifylline, 1.2-1.5 g daily parenterally for ten consecutive days. At the beginning of treatment, on the first and then every third day the following rheological measurements were made: yield shear stress, plasma viscosity, haematocrit, erythrocyte aggregation and deformability. In the course of treatment there was a highly significant improvement in the first and last functions. Plasma viscosity and erythrocyte aggregation did not change significantly. Haematocrit was changed in two patients by isovolaemic haemodilutions. Clinically there was improvement in nine patients; one patient died as a result of severe brainstem ischaemia.

Heroin is commonly abused as a recreational drug and results in huge social, economical, individual, and public health hazards. Heroin affects many organs in abusers' bodies. The most well studied effects of heroin on the brain are dependence and tolerance after extended use. However, heroin also has some less commonly reported effects on the brain. For example, ischemic cerebrovascular accident following heroin use is an infrequent consequence of heroin abuse and is primarily related to impurities in the drug preparation. Another rare consequence of heroin abuse is toxic leukoencephalopathy. Although this is usually associated with heroin inhalation, its precise etiology is not clear. Here, we review existing cases for these two uncommon pathologies as well as suggested mechanisms for them, including mitochondrial impairment.

BACKGROUND: Atrial fibrillation is the most common cardiac arrhythmia and a major risk factor for cerebrovascular accident, including ischemic stroke and transient ischemic attack. HYPOTHESIS: Ischemic cerebrovascular accident is associated with increasing age and cardiovascular and cerebrovascular disease in primary care patients with atrial fibrillation. METHODS: Using the U.K. General Practice Research Database, we identified patients with chronic atrial fibrillation who were alive 1 month after initial diagnosis (n = 906). Potential cases of cerebrovascular accident were identified and confirmed by the primary care physician. The incidence of cerebrovascular accident was calculated. A nested case‐control analysis was performed to identify factors associated with cerebrovascular accident among patients with chronic atrial fibrillation. RESULTS: During a mean follow‐up period of 1.8 years (range: 0–3.9 years), 60 patients with atrial fibrillation were diagnosed with a new cerebrovascular accident (22 cases with transient ischemic attack and 38 with ischemic stroke). The incidence of new cerebrovascular accident was 3.6 per 100 patient‐years (95% confidence interval [CI]: 2.8–4.6). Increased age (odds ratios [OR] compared with age 40–69 years: 3.5 [95% CI: 1.2–10.5] for age 70–79 years and 4.9 [95% CI: 1.6–15.0] for age > years), prior cerebrovascular event (OR: 3.4; 95% CI: 1.9–6.1) and diabetes (OR: 2.2; 95% CI: 1.0–4.9) were identified as risk factors for a new cerebrovascular accident. CONCLUSIONS: Among patients with atrial fibrillation, risk factors for a new ischemic cerebrovascular accident include previous ischemic stroke or transient ischemic attack, comorbid diabetes, and increasing age. Copyright © 2007 Wiley Periodicals, Inc.

Annular elastolytic giant cell granuloma (AEGCG) is a very infrequent granulomatous dermatitis characterized by elastolysis and elastophagocytosis. It usually appears in middle-aged Caucasian women and is normally located in sun-exposed areas. We present a case of a 73-year-old woman with hypertension and type II diabetes, who was admitted to the hospital for an ischemic cerebrovascular accident. She presented with annular and serpiginous skin lesions on her back and arms that had appeared seven months earlier; a clinical and histological diagnosis of elastophagocytic granuloma was made. Our patient exhibited a florid presentation and a self-limiting course.

Neurologic complications are among the principal causes of morbidity and mortality after continuous-flow left ventricular assist device (CF-LVAD) implantation. The aim of this study was to describe a focused "real-world" multicenter comparison of neurologic outcomes between HeartMate II (HMII) and HeartWare HVAD CF-LVAD recipients.Between March 2009 and October 2014, 497 patients underwent primary CF-LVAD implantation as a bridge to transplantation at centers included in the Mechanical Circulatory Support Research Network; 314 patients (63%) received HMII, and 183 patients (37%) received HVAD. Ischemic cerebrovascular accident, hemorrhagic cerebrovascular accident, and transient ischemic attack were the neurologic outcomes assessed.Median follow-up time for HMII recipients was 0.95 years (0.48, 1.85, range) and for HVAD recipients was 0.44 years (0.19, 0.97, range) (p0.001). HMII recipients had significantly fewer neurologic events per patient year for ischemic cerebrovascular accident (0.071) and transient ischemic attack (0.012) compared with HVAD recipients (0.157 and 0.072, respectively). Univariate analysis showed that 51 HMII recipients (16%) had any neurologic event, whereas 34 HVAD recipients (19%) had any neurologic event (p = 0.504). After adjusting for pre-specified covariates (device type, age, sex, atrial fibrillation, diabetes, and Interagency Registry for Mechanically Assisted Circulatory Support profile), multivariable analysis showed only advanced age was able to predict neurologic events (p = 0.02). Neurologic events were comparable between HMII and HVAD recipients after multivariable analysis.CF-LVAD placement incurs a low but significant risk of neurologic complications in patients receiving CF-LVADs as a bridge to transplantation. Advancing age is a risk factor for any adverse neurologic outcome. This multicenter analysis demonstrated comparable hazard of adverse neurologic events among patients implanted with HMII or HVAD.

Atrial fibrillation (AF) is a potent risk factor for ischemic cerebrovascular accident (ICVA). Inflammation is a potential pathogenic factor for atherosclerosis and ICVA. Chronic obstructive pulmonary disease (COPD) is associated with increased inflammatory markers. Subjects who frequently experience COPD and AF together may have higher risk of ICVA. The objective of the study is to compare the prevalence of ICVA in patients with atrial fibrillation and COPD together versus atrial fibrillation alone.Subjects diagnosed with COPD, AF, and ICVA were categorized into 3 groups: COPD, AF, and COPD plus AF. Prevalence of ICVA was compared. Confounding factors affecting ICVA risk were recorded: age, diabetes, hypertension, peripheral vascular disease, dyslipidemia, and congestive cardiac failure.Total charts reviewed were 500: COPD alone 244, AF alone 188, and both together 68. ICVA was documented in 132 (26.4%) subjects. Prevalence of ICVA was 11.8% (COPD alone), 29.8% (AF alone), and 39.7% (AF plus COPD). COPD plus AF group had ICVA 2.05 (95% confidence interval [CI], 1.203-3.94; P = .007) times compared with others. ICVA was also higher in patients with AF only versus COPD only (P.001). Logistic regression showed AF plus COPD was a stronger predictor of ICVA (P = .001) than AF only (P = .07) or COPD only (P = .8). Odds ratio for ICVA was 2.85 (CI, 1.57-5.16; P = .001) for AF plus COPD versus 1.81 (CI, .94-3.47; P = .71) for AF only and 1.08 (CI, .58-2.10; P = .8) for COPD only.COPD may increase the risk of ischemic stroke in subjects with AF. Presence of COPD may increase the risk of ischemic stroke in subjects with AF.

Objetivos: Descrever as variaveis sociodemograficas e clinicas do Acidente Vascular Encefalico (AVCi), correlacionando com deficits cognitivos: orientacao, memoria, percepcao e pensamento abstrato, diagnosticados pelo instrumento de avaliacao neuropsicologico, CAMCOG-R. Materiais e Metodos: Para coleta de dados, foi utilizado um questionario de caracterizacao sociodemografica e clinica e uma avaliacao cognitiva de idosos acometidos por infarto cerebral, decorridos 05 dias, o CAMCOG-R. Resultados: Entre as variaveis estudadas, o fator preditor de sequela no desempenho cognitivo foi a hipertensao, com p=0,032. Apesar do escore global nao apresentar diferenca estatisticamente significativa, em relacao ao tempo de ocorrencia do AVCi, verificou-se que na pontuacao da subescala orientacao espacial, houve uma melhora estatisticamente significativa, com p

Objective: Ischemic cerebrovascular accident (ICA) is characterised by the rapid deterioration of brain function due to vascularization disorders. The ischemic cerebrovascular accident may arise as a consequence of ischemia or hemhorrage in brain tissue, but the optimal treatment approach is unclear. In this study, we examined ICA rehabilitation goals, implementation of rehabilitation plans, management of sensomotor deficits and functional status, improvement of independence, prevention and treatment of complications, functional status monitoring, and planning recommendations, as well as education of ICA patients and their families.Methods: This study considered 69 ICA patients who were classified as suitable for rehabilitation intervention among a total of 231 patients who were evaluated for a diagnosis of ICA following hospitalization at the Clinic of Neurology, University Clinical Center of Kosovo (UCCK) in Prishtina. From the statistical parameters, we used the structure index, whereas testing results were evaluated using the Chi-square test with significance established at p

Background: Following ischemic cerebrovascular accident (CVA) or transient ischemic attack (TIA) aggressive risk factor modification is undertaken to reduce the risk of recurrent events. Holter monitoring is advocated to facilitate the detection and treatment of Atrial Fibrillation (AF). Frequent Premature Atrial Contractions (PACs) are associated with the development of AF, but to date it is unknown whether the burden of PACs on Holters is of any prognostic importance following CVA/TIA. Objective: PACs on Holter monitoring may be a marker for recurrent cerebrovascular events post CVA/TIA. Methods: Retrospective analysis was performed on Holters of patients with CVA/TIA enrolled in a prior population based stroke study. Frequent PACs were defined as a rate of PACs ≥ 100 per 24 hours. The primary endpoint was recurrent CVA or TIA. Results: 84 cases (61.0% male) were reviewed. Mean age was 69.7 ± 12.4 years. Mean time to follow-up was 2514.6 ± 91.2 days. The average number of PACs in the frequent group (Hi-PAC, 21 patients) was 1610.8 ± 4541.4 compared with 21.8 ± 27.6 in those with less than 100 PACs (Lo-PAC, 63 patients). There was no statistically significant difference in age, gender, hypertension or diabetes between the two groups. On follow-up there were 20 recurrent events and 33 patients died. In the Hi-PAC group there were 8 (38.1%) recurrent events, and 16 (76.2%) patients died versus 12 (18.8%) and 17 (26.6%) respectively in Lo-PAC group. On Cox regression analysis the Hazard ratio (HR) for recurrent events was 2.75 (95% confidence interval (CI) 1.08 to 7.01). Kaplan Meier curves revealed a statistically significant difference in recurrance rates between the two groups (p < 0.05). There was also a statistically significant difference in overall mortality on Kaplan Meier survival analysis (p < 0.001), and with a hazard ratio on Cox regression analysis of 3.47 (95% CI 1.74 [[Unable to Display Character: –]] 6.91). There was no significant difference in incidence of MI or AF. Conclusion: Frequent PACs on Holter monitor represent a significant risk factor for both recurrent events and mortality following CVA/TIA. Further prospective studies should be performed to assess whether these patients may benefit from more aggressive anticoagulation, similar to those with AF.

Objective In this research, we sought to determine the association between β-thalassemia trait and ischemic cerebrovascular accident (CVA). Methods In acase-control study, 148 patients with thromboembolic cerebrovascular events were evaluated for the presence of hypertension, diabetes mellitus, hyperlipidemia, and β-thalassemia trait. A total of 156 age- and sex-matched patients with no cardiac or cerebrovascular diseases, serving as the control group, were also investigated for the above-mentioned risk factors. Results We found that 6.1% of patients with ischemic CVA and 12.2% of the control group had β-thalassemia trait ( P = .066). In male patients, the negative association between ischemic CVA and presence of β-thalassemia trait was significant ( P = .008). In patients, the prevalence of hypertension was also significantly different between those with and without β-thalassemia trait ( P = .01); those with β-thalassemia trait had a lower mean blood pressure than those without the trait. Conclusion β-Thalassemia trait may have a protective effect against ischemic CVA that might be caused by the lower arterial blood pressure observed in those with this trait.

Background Although atrial fibrillation (AF) is the most commonly encountered arrhythmia, some of the properties make its detection challenging. In daily practice, underdiagnosis can lead to less effective treatment in prevention of stroke. Based on data from studies on treatment of AF, more intensive follow-up strategies, including 7-day Holter recording, 30-day event recording, and even implantable cardiac monitoring devices, are suggested. The study purpose is to evaluate the performance of a continuous single-channel loop recorder with automatic AF detection and transtelephonic electrocardiogram (ECG) transmission capabilities. Methods and Results A consecutive cohort of 153 patients admitted to the stroke unit with a presumptive diagnosis of ischemic cerebrovascular accident was screened for AF. Twenty-four-hour rhythm observation was performed using a single-channel external loop recorder (ELR) configured for automated AF detection. A total of 45 patients with a known history of AF, AF on the admission ECG, or incomplete registrations were excluded. Extensive additional frequency-based settings were used to establish a reference registration. In total, 2923 recordings were transmitted. We evaluated all events, of which 1190 were designated by the device as AF. The sensitivity, specificity, PPV, and NPV for identifying AF using the ELR were, respectively, 93%, 51%, 5%, and 99%. Conclusions In this ELR validation study, the dedicated AF detection algorithm showed to be highly sensitive but not specific for AF. Applicability of an ELR might be limited for efficacious detection of AF, as manual verification is mandatory for a vast amount of recordings.

Thrombotic thrombocytopenic purpura (TTP), a complex thrombotic microangiopathy, remains an evolving enigma. A 49-year-old African-American woman presented with acute left hemiplegia, an ischemic cerebrovascular accident involving the right middle cerebral artery. Sequential appearance of thrombocytopenia and evidence of microangiopathic haemolysis led to the diagnosis of acquired idiopathic autoimmune TTP. This was managed with plasma exchange (PEX) and steroids. Early haematologic relapse within a month was managed with the addition of rituximab attaining sustained remission. The patient presented 3 years later with acute confusion and expressive aphasia due to multiple infarcts involving the left parieto-occipital cortex. Transoesophageal echocardiography demonstrated a pedunculated 6 mm mitral valvular mass consistent with a papillary fibroelastoma. Anticoagulation was instituted and the patient was continued on therapeutic oral warfarin. A haematologic relapse of TTP eventually emerged and was managed with PEX, steroids and rituximab. This vignette demonstrates several dilemmas in the clinical presentation, diagnosis and management of TTP in current day practice. Rituximab has adjuvant benefits to PEX and is being investigated as potential first-line therapy. Monitoring ADAMTS13 activity and inhibitor titre, as in our case, prove to have prognostic significance. Cardiac fibroelastomas are rare benign cardiac tumours usually arising from valvular endocardium with thromboembolic potential. One of the proposed mechanisms of origin of these masses is organizing thrombi in the setting of endocardial injury and inflammation questioning a possible link to thrombotic microangiopathy. To the best of our knowledge, this is the first report of this unique coexistence.

This resource is a case-based simulation exercise focused on the emergency department evaluation and management of a patient presenting with an acute ischemic cerebrovascular accident (CVA). This educational tool involves one programmed high-fidelity simulation case of a patient with a left-sided CVA. Participants will be expected to manage the care of the patient. Debriefing materials for the management of an ischemic stroke consisting of some review of the literature surrounding the administration of intravenous tissue-type plasminogen activator (iv-TPA) are included. This case is intended to be used with emergency medicine residents, internal medicine residents, and senior-level medical students. The purpose is to prepare residents and students to appropriately manage a patient presenting to an emergency department with an ischemic CVA. This case was administered to approximately 15 emergency medicine residents as students. The goal of the case is to have the learners appropriately assess the patient with an acute CVA in a timely manner, obtain the appropriate imaging studies, evaluate indications and contraindications for a patient who is a potential candidate for iv-TPA, manage significant hypertension, and discuss with the patient the risks and benefits of iv-TPA. This simulation case also provides a venue for practicing departmental protocols surrounding the care of patients who present with acute CVA in a more realistic setting.

In modern medicine brain perfusion imaging is relatively new technique and is very useful in early diagnosis of acute ischemic cerebrovascular accident/stroke. It performs quantitatively and qualitatively to illustrate evaluation of cerebral perfusion by generating three maps of cerebral blood volume (CBV), cerebral blood flow (CBF) and mean transit time (MTT). In this paper we present a comparison based algorithm to delineate ischemic stroke area on processing of computed tomography perfusion (CTP) image data and classification of brain tissue as normal tissue, dead tissue, dying tissue and undefined condition using CBV and MTT maps. Experiment has been carried out on perfusion image data and our approach results agree well with expert neurologist manual delineation and produce satisfactory result.

Patent foramen ovale (PFO) is a frequent condition. It usually does not pose any threat to life, but in certain circumstances, it can open and serve as a conduit for thrombi causing paradoxical embolism. Herein, we report a case of PFO in a patient with ischemic cerebrovascular accident, due to paradoxical embolism, which could not be passed via general practice; hence it was crossed with coronary sinus catheter, through which the delivery sheath was placed into the left atrium, and it was successfully closed.

A 91-year-old patient is brought into the ER. Earlier that day he suffered from severe headache and he had to vomit. His help reports that she saw limb contractions. He did not bite his tongue, nor did he suffer from urinary incontinence. He now suffers from weakness on the left side of his body, which is fortunately improving. He reported to have been confused and have a headache yesterday night, as well. He was admitted to the hospital, with a preliminary diagnosis of an ischemic cerebrovascular accident (CVA, also known as stroke) accompanied by an epileptic seizure.