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Coronary perforation is an uncommon complication of percutaneous coronary intervention (PCI), that, in extreme cases, might result in cardiac tamponade. Here, we describe a case of coronary artery perforation in a 55-year-old female, presented with recent inferior wall myocardial infraction (IWMI). Coronary angiogram represented right coronary artery (RCA) lesion which was planned to manage with PCI. During PCI, coronary perforation emerged in RCA, leading to cardiac tamponade. Hence an immediate pericardiocentesis was performed and coronary perforation was tackled successfully using a covered stent. Keywords: Coronary perforation, percutaneous coronary intervention (PCI), cardiac tamponade, cath lab nightmare.

Introduction: Stroke is a leading cause of economic burden in the Low Middle Income countries (LMIC’s). We want to study the outcome of acute strokes treated under Government scheme with minimal package (For Ischemic Stroke - 257 USD & For hemorrhagic stroke - 399 USD), but offered evidence-based stroke care other than thrombolysis. Methods: From January 2021 to March 2021, a total of 350 cases were treated in our Ankineedu stroke center. Out of these 125 (36%) acute stroke patients are treated under subsidized economical stroke care from admission to discharge. In-patient mortality, 3 months follow up and 1 year follow up recorded. All patients received standard medical treatment in Stroke unit with Antiplatelets, statins, DVT prophylaxis, Antihypertensives, dysphagia assessment, physiotherapy and Neurosurgery when required. All basic stroke investigations done - CT scan, MRI scan, MR Angio, Neck vessel doppler, Lipids, Renal Function test, RBS, ECG and ECHO. All patients discharged on secondary prevention. Average length of stay is 10 days. Results: There were 94 men and 31 women, age ranged from 18 years to 85 years (median 55 yrs). Type of stroke: Ischemic Stroke -74% and Haemorrhagic stroke - 26%, 4 patients (3.2%) underwent Neurosurgery. Risk factors: Hypertension - 82 (66%), Diabetes - 45 (36%), Cardiac problems - 17 (13.6%), Smoking - 20 (16%), Alcohol - 15 (12%). Total In-house mortality 5 (4%) and the remaining patients outcome at 3 months - Good outcome with modified rankin scale (mRS) 0-2 in 83 patients (66%), Fair Outcome with mRS (3-4) - 35 (28%), 1 patient (0.8%) bedridden and 1 patient (0.8%) died at home. Out of 125 patients, 60 patients (48%) came for 1 year follow up, of these 88% had mRS (0-2), 12% had mRS (3-5). Conclusion: In resource poor countries we can offer basic stroke care model to all needy patients with reasonable outcome. However, the follow up needs to be strengthened.

Introduction: Intravenous Thrombolysis is approved upto 4½ hrs and Endovascular Therapy upto 24 hrs in eligible Acute Ischemic Stroke (AIS) patients with Large Vessel Occlusion. There are still substantial number of AIS patients where there is no effective treatment available. In this Study we aim to test the safety and Efficacy of the reversible gp IIb/IIIa receptor inhibitor antagonist Tirofiban in AIS beyond 4 ½ hrs and within 24 hrs. Methodology: Among a total of 750 AIS patients admitted in our Stroke Unit, from July 2019 to March 2020, 100 Consecutive patients were included in this study and received Intravenous tirofiban as an initial bolus followed by infusion. Inclusion criteria were Age 18-80yrs, Window Period 4 ½ to 24 hrs. National Institute of health Stroke Scale score (NIHSS) between 5-20, No contraindication for lytic drugs. CT Brain excluding Hemorrhage or > 1/3 rd infarct. Cardioembolic strokes were excluded. Efficacy Assessments: NIHSS and modified Rankin scale (mRS) performed at baseline, within 48hrs, Day-7 and Day-90. The good outcome was defined as mRS 0-1 at 3 months. The safety outcomes were assessed by the incidence of Symptomatic Intracerebral hemorrhage (SICH), Systemic Bleeding and any mortality. Results: There were 74 males, 26 females with median Age of 56 yrs (range from 18 to 80yrs). The Median NIHSS is 10 (range from 5-20), Majority (87%) had anterior circulation strokes and 13% were in Posterior circulation. One patient (1%) developed symptomatic parenchymal Hemorrhage, 4 patients (4%) had mild haemorrhagic transformation within infarct, 8 patients (8%) had nonfatal systemic bleed in the form of Hematuria. Total Mortality - 2 patients (2%), one patient died in the hospital due to cardiac arrest and another patient died at home after discharge. At 3 months, 62 patients (62%) had good outcome (mRS 0-1) and 33 patients (33%) had favourable outcome (mRS 2-3). Conclusion: In this Observational Study we found that Intravenous Tirofiban is not only safe, but effective in AIS patients with extended window period. However, Randomized Clinical Trials are needed to further clarify our observation.

Background and Purpose: Occurrence of stroke has been reported among patients with COVID-19. The present study compares clinical features and outcomes of stroke patients with and without COVID-19. Methods: The COVID-19 Stroke Study Group (CSSG) is a multicentric study in 18 sites across India to observe and compare the clinical characteristics of patients with stroke admitted during the current pandemic period and a similar epoch in 2019. The present study reports patients of stroke with and without COVID-19 (CoVS and non-CoVS, respectively) seen between February 2020 and July 2020. Demographic, clinical, treatment, and outcome details of patients were collected. Results: The mean age and gender were comparable between the two groups. CoVS patients had higher stroke severity and extent of cerebral involvement on imaging. In-hospital complications and death were higher among CoVS patients (53.06% vs. 17.51%; P < 0.001) and (42.31% vs. 7.6%; P < 0.001), respectively. At 3 months, higher mortality was observed among CoVS patients (67.65% vs. 13.43%; P < 0.001) and good outcome (modified Rankin score [mRS]: 0–2) was seen more often in non-CoVS patients (68.86% vs. 33.33%; P < 0.001). The presence of COVID-19 and baseline stroke severity were independent predictors of mortality. Conclusions: CoVS is associated with higher severity, poor outcome, and increased mortality. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and baseline stroke severity are independent predictors of mortality.

BACKGROUND The FLEX-LONG study assessed the safety and clinical outcomes of ultra-long (44 mm/48 mm) biodegradable polymer-coated Supraflex (Sahajanand Medical Technology Pvt. Ltd., Surat, India) sirolimus-eluting stents (SES) in real-world patients with complex, long coronary artery lesions. METHODS It was an investigator-initiated, retrospective, non-randomized, observational and single-center study, which evaluated one-year results of 141 patients who had undergone implantation of at least one ultra-long (44 mm/48 mm) Supraflex SES. The incidence of major adverse cardiac events (MACE), a composite of cardiac death, myocardial infarction (MI) and target lesion revascularization (TLR), at one-year follow-up was considered as primary outcome. Stent thrombosis was analyzed as a safety outcome. RESULTS The mean age of the study population was 56.2±9.6 years and 78.0% (110/141) patients were male. The study analyzed high risk patients, including 62 (44.0%) hypertensive and 60 (42.6%) diabetic patients. Total 147 target lesions were treated, including 25 (17.0%) total occlusions. Total 51 (34.7%) and 96 (65.3%) Supraflex SES of 44 mm and 48 mm were implanted, respectively. Average stent length and diameter were 46.6±1.9 mm and 3.4±0.2 mm, respectively. One-year follow-up was obtained in 100% of patients. There was one probable stent thrombosis after three weeks. At one-year follow-up, 99.3% of patients remained event free. CONCLUSIONS The results of the FLEX-LONG study support the use of ultra-long (44 mm/48 mm) Supraflex SES, in the treatment of high-risk real-world patients. The stent appeared to be safe and effective at one-year with low clinical events in complex, long coronary artery lesions.

Background The registry investigated clinical outcomes after 12 months of implantation of ultra-thin strut (60 µm) biodegradable polymer-coated Tetrilimus everolimus-eluting stents (EES; Sahajanand Medical Technologies Pvt. Ltd., Surat, India) in patients with atherosclerotic coronary lesions. Additionally, sub-group analysis was performed to evaluate outcomes of ultra-long (44/48 mm) Tetrilimus EES in patients with long lesions. Methods This was an observational, single-center, single-arm and investigator-initiated retrospective registry. In this all-comers registry, patients who underwent implantation of Tetrilimus EES for treatment of coronary artery disease during routine clinical practice between February-2016 and August-2016 at tertiary care center of India were included. Primary endpoint was occurrence of any major adverse cardiac event (MACE) up to 12 months' follow-up. MACE was a composite of cardiac death, myocardial infarction (MI), and target lesion revascularization (TLR). Similar endpoints were observed in sub-group patients. Results Total 766 stents were implanted to treat 695 lesions in 558 patients. Of treated lesions, 11.4% lesions were type B2 and 78.3% were type C lesions. In sub-group analysis of 143 patients, a total of 155 long coronary lesions were intervened successfully with only one stent been implanted per lesion. At 12 months' follow-up, four (0.7%) cases of cardiac death, eight (1.4%) of MI, and two (0.4%) of TLR were reported, resulting in a 2.5% rate of MACE. The MACE rate was 2.8% in sub-group patients. Conclusions Twelve months' clinical data demonstrated favorable safety and excellent performance of Tetrilimus EES in high-risk patients and complex coronary lesions in routine clinical practice and also in patients with ultra-long lesions.

Supplemental Digital Content is available in the text., Background and Purpose: Among patients with a transient ischemic attack or minor ischemic strokes, those with ipsilateral atherosclerotic stenosis of cervicocranial vasculature have the highest risk of recurrent vascular events. Methods: In the double-blind THALES (The Acute Stroke or Transient Ischemic Attack Treated With Ticagrelor and ASA for Prevention of Stroke and Death) trial, we randomized patients with a noncardioembolic, nonsevere ischemic stroke, or high-risk transient ischemic attack to ticagrelor (180 mg loading dose on day 1 followed by 90 mg twice daily for days 2–30) or placebo added to aspirin (300–325 mg on day 1 followed by 75–100 mg daily for days 2–30) within 24 hours of symptom onset. The present paper reports a prespecified analysis in patients with and without ipsilateral, potentially causal atherosclerotic stenosis ≥30% of cervicocranial vasculature. The primary end point was time to the occurrence of stroke or death within 30 days. Results: Of 11 016 randomized patients, 2351 (21.3%) patients had an ipsilateral atherosclerotic stenosis. After 30 days, a primary end point occurred in 92/1136 (8.1%) patients with ipsilateral stenosis randomized to ticagrelor and in 132/1215 (10.9%) randomized to placebo (hazard ratio 0.73 [95% CI, 0.56–0.96], P=0.023) resulting in a number needed to treat of 34 (95% CI, 19–171). In patients without ipsilateral stenosis, the corresponding event rate was 211/4387 (4.8%) and 230/4278 (5.4%), respectively (hazard ratio, 0.89 [95% CI, 0.74–1.08]; P=0.23, Pinteraction=0.245). Severe bleeding occurred in 4 (0.4%) and 3 (0.2%) patients with ipsilateral atherosclerotic stenosis on ticagrelor and on placebo, respectively (P=NS), and in 24 (0.5%) and 4 (0.1%), respectively, in 8665 patients without ipsilateral stenosis (hazard ratio=5.87 [95% CI, 2.04–16.9], P=0.001). Conclusions: In this exploratory analysis comparing ticagrelor added to aspirin to aspirin alone, we found no treatment by ipsilateral atherosclerosis stenosis subgroup interaction but did identify a higher absolute risk and a greater absolute risk reduction of stroke or death at 30 days in patients with ipsilateral atherosclerosis stenosis than in those without. In this easily identified population, ticagrelor added to aspirin provided a clinically meaningful benefit with a number needed to treat of 34 (95% CI, 19–171). Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03354429.

Background As the health systems around the world struggled to meet the challenges of COVID-19 pandemic, care of many non-COVID emergencies was affected. Aims The present study examined differences in the diagnosis, evaluation and management of stroke patients during a defined period in the ongoing pandemic in 2020 when compared to a similar epoch in year 2019. Methods The COVID stroke study group (CSSG) India, included 18 stroke centres spread across the country. Data was collected prospectively between February and July 2020 and retrospectively for the same period in 2019. Details of demographics, stroke evaluation, treatment, in-hospital and three months outcomes were collected and compared between these two time points. Results A total of 2549 patients were seen in both study periods; 1237 patients (48.53%) in 2019 and 1312 (51.47%) in 2020. Although the overall number of stroke patients and rates of thrombolysis were comparable, a significant decline was observed in the month of April 2020, during the initial period of the pandemic and lockdown. Endovascular treatment reduced significantly and longer door to needle and CT to needle times were observed in 2020. Although mortality was higher in 2020, proportion of patients with good outcome were similar in both the study periods. Conclusions Although stroke admissions and rates of thrombolysis were comparable, some work flow metrics were delayed, endovascular stroke treatment rates declined and mortality was higher during the pandemic study period. Reorganization of stroke treatment pathways during the pandemic has likely improved the stroke care delivery across the globe.

Background: The aim of the present study is to determine the role of simultaneous carotid artery stenting in high-risk patients with triple vessel coronary artery disease and to determine the safety and efficacy of the procedure in these cases. Materials and Methods: The present study is a retrospective analysis of 33 patients who underwent carotid artery stenting in the same setting in our institution from 2009 to 2016. There were 22 male and 11 females with a mean age of 65 years (53–76 years). Demographic factors clinical characteristics and atherosclerosis risk factors were documented. Results: Technical success was 100% in our series. Intraprocedural and postprocedural events in the form of hypotension and bradycardia due to hemodynamic depression were seen in 11 patients. We did not encounter hyperperfusion syndrome in any of our patients. Twenty-nine patients underwent cardiac bypass surgery after 3 weeks, and 4 patients were kept on medical management for coronary artery disease. No deaths or major strokes occurred in our series. Conclusion: Simultaneous bilateral carotid artery stenting is a safe treatment option even in patients with high-risk factors and can be considered as the therapeutic option in patients with significant bilateral carotid artery disease.

Though percutaneous transcatheter atrial septal defect closure with newer generation occluder devices is a standard treatment at present, these devices have significant long-term risks (>1 year) associated with such as thrombus formation. Here, we present a case of 28 year-old patient presented with few symptoms and had a history of ASD device closure using amplatzer septal occluder device five years back. The patient was found to have a large thrombus (30×33 mm) attached to the device which was managed using anticoagulants and patients was advised for regular echocardiographic follow-up.

Background The risk of falls in people with Multiple Sclerosis (MS) is much greater than that of the general population due to impaired coordination, gait, sensation, muscle tone, strength, and cognition. These MS related falls hamper the day to day living of these individuals and are one of the prime factors aggravating the disease related morbidity. The fear of falling itself may make these individuals more dependent and hinder their professional and leisurely activities. Hence, the significance of identifying individuals who are at risk of falling and instituting preventive counter-measures cannot be overemphasized. Various simple clinical tests and questionnaires have been recommended for this purpose, but are far from ideal. Objective The objective was to find accurate measures to predict a future fall in MS patients. We also aimed to enquire about the prevalence of falls in MS population and its clinical profile which included detailed history about the past falls, Expanded disability status scale (EDSS) scores, Timed 25 foot walk (T25FW) scores, Activities specific balance confidence (ABC) scores, Falls efficacy scale international (FESI) scores, Multiple Sclerosis Walking Scale 12 (MSWS12) questionnaire. Design/Methods This was a prospective cohort study conducted at the Institute of Neurology, Chennai from January 2015 to August 2017. MS patients of any subtype attending Neurology OPD satisfying revised 2010 McDonald criteria were recruited. 134 subjects with MS consented to participate in this study and 113 of them who met the criteria were included. Baseline history was obtained about the number of falls in the previous year. EDSS, T25FW, ABC, FESI, and MSWS12 scores were obtained at the baseline. VEMP and SEP tests were done and the baseline P13/N23 cVEMP latencies, N10 oVEMP latency, and P37 lower limb SEP latency were obtained. These subjects were followed up for one year and were enquired if they had fallen during that period and the number of falls was recorded. Logistic regression models were used to compute the area under receiver operating characteristic curve (AUC) for each variable tested. Pearson correlation coefficients were calculated for each variable with the number of future falls. Results Among the 113 patients, 72% (n = 81) had one or more falls during follow-up. Among all variables tested P13 cervical VEMP latency had the highest predictive accuracy (AUC = 0.820) followed by N10 ocular VEMP latency (AUC = 0.794) and P37 SEP latency (AUC = 0.732). P13 latency also had the highest correlation coefficient (R = 0.689, R2 = 0.475) with the number of future falls. Conclusion P13, N10 and P37 latencies were the most accurate in predicting a future fall when compared to clinical measures.