The Emerging Clinical Utility of Neurosonology During COVID-19 Pandemic

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 infection. Over the last 2 years the virus has spread worldwide with enormous implications on the healthcare systems. COVID-19 patients suffer from mild upper-airway manifestations to pneumonia and severe acute respiratory distress syndrome and their hospitalizations are often prolonged. Neurological manifestations of the disease are common. Neurosonology (transcranial Doppler & cervical duplex ultrasound) is an easily repeatable diagnostic imaging modality that can be simply applied at the bedside of COVID-19 patients with cerebrovascular diseases or in critically ill patients in the intensive care unit. Neurosonology may provide hemodynamic assessment of cerebral circulation, quantitative evaluation of increased intracranial pressure and detection of micro-embolic signals in real-time. Consequently, it may assist substantially in the diagnosis, risk stratification and therapeutic approach of COVID-19 patients with or without cerebrovascular complications. In the present narrative review, we discuss the emerging clinical utility of neurosonology during COVID-19 pandemic and highlight the upgraded role of neurosonology resulting from the combination of the established applications coupled with the reduced risk of virus spreading during ultrasound evaluation compared to other imaging modalities including computed tomography and magnetic resonance imaging.

Influence of steep Trendelenburg position on postoperative complications: a systematic review and meta-analysis

Intraoperative physiologic changes related to the steep Trendelenburg position have been investigated with the widespread adoption of robot-assisted pelvic surgery (RAPS). However, the impact of the steep Trendelenburg position on postoperative complications remains unclear. We conducted a meta-analysis to compare RAPS to laparoscopic/open pelvic surgery with regards to the rates of venous thromboembolism (VTE), cardiac, and cerebrovascular complications. Meta-regression was performed to evaluate the influence of confounding risk factors. Ten randomized controlled trials (RCTs) and 47 non-randomized controlled studies (NRSs), with a total of 380,125 patients, were included. Although RAPS was associated with a decreased risk of VTE and cardiac complications compared to laparoscopic/open pelvic surgery in NRSs [risk ratio (RR), 0.59; 95% CI 0.51–0.72, p < 0.001 and RR 0.93; 95% CI 0.58–1.50, p = 0.78, respectively], these differences were not confirmed in RCTs (RR 0.92; 95% CI 0.52–1.62, p = 0.77 and RR 0.93; 95% CI 0.58–1.50, p = 0.78, respectively). In subgroup analyses of laparoscopic surgery, there was no significant difference in the risk of VTE and cardiac complications in both RCTs and NRSs. In the meta-regression, none of the risk factors were found to be associated with heterogeneity. Furthermore, no significant difference was observed in cerebrovascular complications between RAPS and laparoscopic/open pelvic surgery. Our meta-analysis suggests that the steep Trendelenburg position does not seem to affect postoperative complications and, therefore, can be considered safe with regard to the risk of VTE, cardiac, and cerebrovascular complications. However, proper individualized preventive measures should still be implemented during all surgeries including RAPS to warrant patient safety.

Prognostic value of net water uptake in acute ischemic stroke: a protocol for a systematic review and meta-analysis

Review question / Objective: The purpose of this protocol is to present a transparent and clear methodology for performing a systematic review and meta-analysis of the available literature aimed to answer the following question: among patients with acute ischemic stroke due to large vessel occlusion, is net water uptake (NWU), as measured in CT images, associated with (i) cerebrovascular complications, including malignant cerebral edema, secondary intracerebral hemorrhage, and (ii) post-stroke functional outcome as measured by the modified Rankin Scale. Condition being studied: Currently, the association between net water uptake with cerebrovascular complications or post-stroke functional outcomes is not well defined. Broocks found that NWU based on CT was an important marker for malignant edema in LVO patients and independently associated with clinical prognosis. Additionally, Nawabi indicated that a higher degree of NWU was a predictor of intracranial hemorrhage in patients with acute ischemic stroke treated with mechanical thrombectomy. Thus, a higher NWU might contribute to the development of stroke complications and poorer outcomes. However, no systematic review and meta-analysis to quantitatively summarize this evidence and help establish the predictive value of NWU in patients with acute ischemic stroke.

Diagnostics of cerebral venous thrombosis associated with COVID-19 in young adults: clinical characteristics and imaging patterns

Introduction. Cerebral venous thrombosis (CVT) is relatively rare, but leads to the development of cerebral venous infarction, intracranial hemorrhage, followed by severe disability and death. Due to the epidemiological situation caused by COVID-19, the incidence of CVT is increasing.Aims and objectives: to analyze clinical, laboratory instrumental and neuroimaging (multislice computed tomography (MSCT), MSCT — with intravenous contrast, magnetic resonance imaging of the brain (MRI) and MRI venography) data that confirmed the development of CVT in patients with COVID-19.Methods. Data of 5 young adults with cerebral venous thrombosis (CVT) associated with COVID-19 are presented.Results. Аmong 5 reported cases of COVID-19, two patients presented with venous infarcts (hemorrhagic and ischemic), 3 patients developed encephalopathy syndrome without acute cerebral infarction.Conclusion. Possibilities of modern imaging technologies permitted to timely diagnosis cerebral venous thrombosis associated with COVID-19, that can lead to immediate initiation of therapy and to prevent the development of cerebrovascular complications during the COVID-19 pandemic.

Transapical cannulation for surgical repair of chronic type B aortic dissection

Open surgery for chronic type B aortic dissection has been shown to have considerable risks of cerebrovascular complications. Because retrograde perfusion is a potential cause of intraoperative cerebrovascular events, we report our transapical cannulation strategy for descending aorta replacement in chronic type B aortic dissection repair with circulatory arrest. This technique provides an easy and quick establishment of cardiopulmonary bypass by way of a left thoracotomy, and prevention of cerebrovascular event. Transapical cannula can be also used as a vent to ensure a bloodless field during proximal anastomosis and to prevent extension of left ventricle during rewarming. Transapical cannulation is a useful option in open repair of the descending aorta for chronic type B aortic dissection by way of left thoracotomy.

Effect of Hierarchical Nursing Management in Patients with Hypertension Complicated with Cardiovascular and Cerebrovascular Risk Factors

Hierarchical management is an essential component of nurse post management and an unavoidable tendency in nursing education. According to their existing condition, various hospitals around the country have actively tested the hierarchical usage and management model of clinical nurses, with some success. The application impact of hierarchical nursing care in patients with hypertension complicated by cardiovascular and cerebrovascular risk factors is the focus of this research. In a hospital, 300 patients with hypertension complicated by cardiovascular and cerebrovascular risk factors were chosen. All patients were split into two groups using the coin-throwing random method: the observation group received hierarchical nurse management and the control group received regular nursing management, with 150 cases in each group. The two groups’ blood pressure, blood lipids, blood glucose, poor habits, rehospitalization rate, and cardiovascular and cerebrovascular problems were also examined. At the same time, the patients’ poor mood and quality of life were assessed before and after the intervention. In the control group followed up for 1 year, the blood pressure compliance rate was 44.88%, the blood lipid compliance rate was 28.65%, the blood glucose compliance rate was 45.00%, the smokers with bad lifestyle habits were 26.57%, the overweight and obese were 23.5%, the high sodium was 31.67%, the rehospitalization rate was 15.48%, and the incidence of cardiovascular and cerebrovascular complications was 43.00%. The observation group’s blood pressure, blood lipids, and blood sugar compliance rates rose substantially ( P = 0.05 ) as compared to the control group. The occurrence of poor luck living habits, the rate of rehospitalization, and the incidence of cardiovascular and cerebrovascular complications were significantly reduced ( P < 0.05 ). Before nursing intervention, there was no significant difference in the bad mood scores SAS, SDS, and quality of life between the two groups of patients ( P > 0.05 ); after nursing intervention, compared with the control group, the observation group’s bad mood scores were significantly reduced, physical factors, psychological factors, and total scores all increased significantly, and the difference was statistically significant ( P < 0.05 ).

Acute Ischemic Stroke in a Young Child and Its Association with SARS-CoV-2 Infection

The coronavirus disease 2019 (COVID-19) in children has been shown to have lower morbidity and mortality in children as compared with adults. The neurological complications related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are increasingly reported in children, yet the cerebrovascular complications are rare. We report a case of a toddler who presented with right-sided hemiparesis and motor aphasia, with an antecedent history suggestive of COVID-19 infection. The child tested negative on the nasopharyngeal swab for real-time reverse transcription-polymerase chain reaction (RT-PCR), but the serology for anti-SARS-CoV-2 IgG assay was positive. The neuroimaging showed an acute infarct in the left middle cerebral artery territory. A detailed evaluation for causes of childhood stroke was unrevealing, except for the presence of severe iron deficiency anemia (IDA). The child was diagnosed as acute ischemic stroke (AIS) most probably secondary to mild COVID-19 infection. The objective of this case report is to explain the possibility of AIS after a mild COVID-19 infection, complicated by the underlying severe IDA. Therefore, an association between COVID-19 and stroke in children needs to be emphasized and RT-PCR for SARS-CoV-2 as well as serological assay must be included in the workup of stroke in the young.

Orthostatic hypotension and atrial fibrillation: is there a relationship?

Orthostatic hypotension (OH), a possible marker of autonomic dysfunction, reflects the inability of reflex cardiovascular mechanisms to compensate for the fall in venous return in the upright position. This is a manifestation of structural and functional abnormalities of the cardiovascular system. Significance of the orthostatic hypotension is underestimated, while it is associated with all-cause mortality and cardiovascular disease. The article reviews the relationship between atrial fibrillation (AF) and OH. The pathogenetic mechanisms of OH are considered, including various subgroups, e. g. elderly patients. The article also discusses the relationship between OH, AF and cerebrovascular complications. Available evidence suggests that impaired orthostatic hemodynamic response should be considered as a new risk factor for AF. Further research is needed for better understanding of the association between AF and OH, as well as their management.

Disruption of the Blood-Brain Barrier by Extracellular Vesicles From Preeclampsia Plasma and Hypoxic Placentae: Attenuation by Magnesium Sulfate

Preeclampsia, a pregnancy-related endothelial disorder, is associated with both cardiovascular and cerebrovascular complications. Preeclampsia requires the presence of a placenta as part of its pathophysiology, yet the role of this organ in the cerebrovascular complications remains unclear. Research has shown that circulating small extracellular vesicles (also known as exosomes) present in preeclampsia plasma can generate endothelial dysfunction, but it is unclear whether the impairment of function of brain endothelial cells at the blood-brain barrier is secondary to plasma-derived or placental-derived exosomes. In this study, we evaluated the effect of small extracellular vesicles isolated from plasma samples of women with preeclampsia (n=12) and women with normal pregnancy (n=11) as well as from human placental explants from normotensive pregnancies (n=6) subjected to hypoxia (1% oxygen) on the integrity of the blood-brain barrier, using both in vitro and animal models. Exposure of human-derived brain endothelial cell monolayers to plasma and plasma-derived small extracellular vesicles from preeclamptic pregnancies increased the permeability and reduced the transendothelial electrical resistance. A similar outcome was observed with hypoxic placental-derived small extracellular vesicles, which also increased the permeability to Evan’s blue in the brain of C57BL6 nonpregnant mice. Cotreatment with magnesium sulfate reversed the effects elicited by plasma, plasma-derived, and hypoxic placental-derived small extracellular vesicles in the employed models. Thus, circulating small extracellular vesicles in plasma from women with preeclampsia or from hypoxic placentae disrupt the blood-brain barrier, which can be prevented using magnesium sulfate. These findings provide new insights into the pathophysiology of cerebral complications associated with preeclampsia.