Concurrent pulmonary arteriovenous malformation and pulmonary embolism causing stroke: a therapeutic dilemma

Background As pulmonary arteriovenous malformation (PAVM) include a right-to-left shunt, it can be accompanied by fatal complications such as stroke and brain abscess due to paradoxical embolism. A concurrent PAVM and pulmonary embolism (PE) is a rare condition. Therefore, the sequence of management has not been established. Case presentation A 62-year-old female patient was transferred to our hospital with a sporadic simple PAVM and concurrent bilateral PE. On chest computed tomography (CT), the acute PE was extended to the segmental pulmonary artery where the feeding artery of PAVM originated. Despite the anticoagulation, the patient complained of left sided weakness on the fifth day of admission, and magnetic resonance imaging revealed an acute infarction in the right lateral thalamus, which was thought to be caused by paradoxical embolism. This situation could lead to a dilemma between the risk of thrombus migration during PAVM embolization and another embolic event due to delayed shunt occlusion during anticoagulation. After a multidisciplinary discussion, a delayed endovascular embolization was performed for PAVM after confirming the complete resolution of PE with 4 months of anticoagulation. The cause of PE in this patient was eventually diagnosed as antiphospholipid syndrome. Conclusion The authors reported a rare case of concurrent PAVM and PE that led to an embolic stroke during hospitalization. This patient was managed with delayed endovascular embolization for PAVM after an anticoagulation for PE and stroke. It is thought to be valuable in deciding for a treatment plan for this rare condition.

Transient Ischemic Attack

The transient ischemic attack is a neurological emergency which is a clinical view of focal cerebral, retinal, or spinal dysfunction that lasts less than an hour, without any detectable acute infarction in neurological imaging methods. TIA is a serious warning for ischemic stroke, and this risk is particularly high in the first 48 hours. Following TIAs, approximately 10-15% of patients undergo stroke in 90 days and about half of these patients suffer a stroke in the first two days. Neuroimaging and laboratory studies should be performed quickly to reveal the etiology and to reduce the risk of stroke that may develop in patients present with TIA. Therapeutic and preventive interventions should be started as soon as possible. With early diagnosis and treatment, the risk of a 90-day stroke in these patients can be reduced by 80%. In addition to antiplatelet and anticoagulant treatments, aggressive control of blood pressure, regulation of blood sugar, statin, dietary recommendations, exercise, and managing the other underlying specific conditions should be started quickly.

Rescue embolization with direct coil delivery from dual-lumen balloon microcatheter

Background Balloon microcatheters are widely used for endovascular treatment. However, no reports on direct coil embolization from dual-lumen balloon microcatheters are available in the literature. This report is the first description of direct coil embolization using this type of balloon microcatheter for looming bleeding emergencies. Methods This retrospective review demonstrates the indications and advantages of coil embolization from an inflated balloon catheter to reduce blood loss and simultaneously occlude bleeding. Results Five patients who underwent emergency endovascular treatment using coil embolization directly delivered from a dual-lumen balloon were identified. Etiologies included vertebro-vertebral arteriovenous fistula, ruptured vertebral artery dissecting aneurysm, vertebral artery injury during cervical spinal operation, and failed stent retrieval procedures for acute infarction. Complete hemostasis was achieved with all procedures. Conclusion Our experience demonstrates the feasibility of direct coil embolization by using a dual-lumen balloon to rapidly halt bleeding in some rare emergency situations, which may save lives.

Combined administration of laminin-221 and prostacyclin agonist enhances endogenous cardiac repair in an acute infarct rat heart

Although endogenous cardiac repair by recruitment of stem cells may serve as a therapeutic approach to healing a damaged heart, how to effectively enhance the migration of stem cells to the damaged heart is unclear. Here, we examined whether the combined administration of prostacyclin agonist (ONO1301), a multiple-cytokine inducer, and stem cell niche laminin-221 (LM221), enhances regeneration through endogenous cardiac repair. We administered ONO1301- and LM221-immersed sheets, LM221-immersed sheets, ONO1301-immersed sheets, and PBS-immersed sheets (control) to an acute infarction rat model. Four weeks later, cardiac function, histology, and cytokine expression were analysed. The combined administration of LM221 and ONO1301 upregulated angiogenic and chemotactic factors in the myocardium after 4 weeks and enhanced the accumulation of ILB4 positive cells, SMA positive cells, and platelet-derived growth factor receptor alpha (PDGFRα) and CD90 double-positive cells, leading to the generation of mature microvascular networks. Interstitial fibrosis reduced and functional recovery was prominent in LM221- and ONO1301-administrated hearts as compared with those in ONO1301-administrated or control hearts. LM221 and ONO1301 combination enhanced recruitment of PDGFRα and CD90 double-positive cells, maturation of vessels, and functional recovery in rat acute myocardial infarction hearts, highlighting a new promising acellular approach for the failed heart.

Type 1 diabetes management and hospitalisation in the over 25’s at an Australian outer urban diabetes clinic

AimsTo describe clinic management and referral pathways among adults with type 1 diabetes (T1D) aged >25 years attending a public outpatient diabetes service. MethodsRetrospective cohort study of people with T1D aged >25 years seen by endocrinologists in one Australian urban public outpatient in 2017. Electronic and paper medical records were reviewed using a dataset adapted from the UK National Institute for Health and Care Excellence 2015 guidelines. ResultsAmong the 111 people with T1D (mean age 41 ± 13 years, 55% men, mean body mass index 27.1 ± 5.6 kg/m2), mean HbA1c was 8.1 ± 1.9% (66 ± 19 mmol/mol) (lower than the Australian National Diabetes Audit: 8.5%/69 mmol/mol) with 25.5% meeting the guideline target of <53 mmol/mol (7.0%). Most people had seen a diabetes educator (80.2%) or dietitian (73.0%) and had complication screening. Complication rates were high (nephropathy 20.4%, retinopathy 27.4%, peripheral neuropathy 30.1%, ischaemic heart disease/acute infarction 10.5%). Overall, 27% of referrals occurred following an acute inpatient admission or emergency department presentation and 13% for management of diabetes in pregnancy. ConclusionsA high proportion of people with T1D accessed public specialist care either during pregnancy or after a largely avoidable acute glycaemia-related hospital presentation. Subsequent care was in line with national specialist standards. This area has a “wait for acute event” rather than “complication prevention” model of care, associated with under-referral to the local multidisciplinary specialist service. Understanding how widespread this model of care is, and ways to reduce its prevalence, are urgently required.

Role of Magnetic Resonance Angiography in Evaluation of Brain Pathologies

Background: MR angiography is the latest technique for the evaluation of cerebrovascular diseases. It is now used commonly for the evaluation of brain pathologies. The advantage is it is a non-invasive method of brain vasculature. The present study aimed to evaluate the role of Magnetic Resonance Angiography in the detection of brain pathologies and to study the Role of Magnetic Resonance Angiography in Cerebral Arteriovenous Malformations, Aneurysms, and Cerebral infarctions. Methods: Data for the study was collected from patients with clinically suspected cerebral lesions or from patients, in whom previous images depicted cerebral lesions, undergoing MRA for evaluation of cerebral lesions Patients underwent MR imaging including TOF Magnetic resonance angiography according to the set protocols after obtaining informed consent. All these patients had undergone detailed clinical evaluation by the referring neurosurgery unit. Results: In this study, a total of n=32 cases were included out of which n=6(18.75%) were AVM, n=10(31.25%) were Aneurysms, and n=16(50%) were cases of infarcts. Of the total n=16 infarct cases n=8(50%) were found in the middle cerebral artery (MCA) n=4(25%) in ACOM and n=2 in PCOM, as well as Internal carotid artery (ICA). Of the MCA cases n=5(62.5%) were right-sided and n=3(37.5%) were left-sided. Conclusion: MRA is now in routine use as a non-invasive tool for imaging the cerebralvasculature. In cerebrovascular disease, it is the investigation of choice forpatients who are suspected/ increased risk of having unruptured intracranial aneurysms, and intracranial vascular disease associated with acute infarction ,intracranial dissection of the carotid and/or vertebral arteries, and follow up cases of Cerebral AVMs.

SWI as a promising tool comparable to CT perfusion in evaluation of acute cerebral infarction

Background The recent advances in magnetic resonance imaging techniques have improved the assessment of acute stroke. Susceptibility weighted imaging (SWI) has a crucial role in the management plan of cerebral ischemia. This study was aimed to assess the role of susceptibility-weighted imaging in assessment of area at risk (pneumbra) compared to CT perfusion in patients with acute ischemic infraction. Results We found the mean aspect score for SWI 4 ± 1.4 and mean aspect for DWI 7.6 ± 1.2; in addition, mean aspect for CTP was 4.6 ± 1.3. Significant difference is noted between the SWI and DWI with significant p value. But there is no significant difference between the SWI and CTP ASPECT scores. Conclusion SWI is a promising technique and comparable to CT perfusion is evaluation of penumbra in the settings of acute infarction.

Imaging of Acute Stroke patient with Covid-19: A serial case

Background: Coronavirus Disease 2019 (COVID-19) has been declared as a pandemic in March 2020 by WHO. Apart from respiratory symptoms, COVID-19 is also associated with various neurological manifestations, one of which is stroke. We reported three cases with diagnosis of stroke in confirmed COVID-19 patients. Case Presentation: Head CT scan without contrast in the three reported cases showed different types of strokes. The first case showed ischemia in the right insular lobe and right parietal lobe. The second case showed intracerebral hemorrhage in the left thalamus and intraventricular hemorrhage, whereas the third case showed acute infarction in right frontotemporal lobe, right lentiform nucleus, right insular cortex, that supports prelenticulostriate segment I MCA embolism. Conclusion: CT scan is an important imaging modality in stroke cases both in COVID-19 and non-COVID-19 cases. CT scans are good at detecting the presence of bleeding, widely available, faster to operate, and less expensive than MRI. The types of stroke in COVID-19 patients can appear as different types of stroke. Generally, it appears as ischemic stroke, but hemorrhagic stroke can also occur with a less frequent occurrence. Further research is needed to explain the exact correlation between stroke and COVID-19.

Left Ventricular Chord Masquerading As An Aortic Valve Papillary Fibroelastoma

Background Characterization of cardiac masses and anomalies is challenging and usually requires multimodality imaging. Herein, we present the case of a left ventricular chord masquerading as an aortic valve papillary fibroelastoma. Case summary In this case, a 62-year-old woman presented with acute right foot weakness. Brain imaging showed multiple areas of acute infarction concerning for a cardioembolic stroke. Transesophageal echocardiography revealed a mass, which was thought to be a papillary fibroelastoma, attached to the non-coronary cusp of the aortic valve. The patient underwent surgical excision of the mass which turned out to be a left ventricular chord crossing the aortic valve and attaching to the left aortic sinus of Valsalva. Conclusion This case underlines the importance of close examination of the aortic subvalvular apparatus when assessing aortic valve masses.

Possi bilities and perspectives of colchicine application in complex therapy in patients with COVID-19

The new coronavirus infection, which has become a pandemic, is greatly increasing interest in the search for new pharmacological drugs with antiviral and anti-infl ammatory properties. Colchicine, which has been used in medicine for centuries and has been mainly known as arthrifuge, has come to be unexpectedly considered as a drug aff ecting the cumulative endpoint in outpatients, including death and hospitalization requirement in a recent large, well-planned, randomized controlled trial. The article provides data on the pharmacodynamics of the drug, which consists in blockade of infl ammasome activation in patients with COVID-19, and an eff ective impact on the mechanisms of “cytokine storm” — a predictor of acute respiratory distress syndrome and sepsis as a major cause of multi-organ lesions and death. The information that its spectrum of anti-infl ammatory activity may explain the vasoprotective eff ects in patients with coronary heart disease (CHD) who underwent acute infarction in the COLCOT study, is particularly attractive from the point of view of the perspectives for the oral colchicine application in COVID-19. High tolerability of the drug, the absence of severe adverse reactions, simple dosing regimen, low cost of colchicine, the absence of signifi cant drug interactions are additional advantages. The authors of this article believe that this information is suffi cient for planning a study of the eff ectiveness of colchicine as an element of complex therapy in hospitalized patients with COVID-19 in combination with acute coronary syndrome, including the need for percutaneous coronary intervention. Early anti-infl ammatory therapy in patients with COVID-19 is still not recommended, despi te th e fact t h at there comes an understanding of its necessity. And in this situation, colchicine has the potential to challenge.