Study on incidence of silent cerebral ischemia among diabetic nephropathy patients admitted in tertiary care hospital

Background: Diabetes accelerates the atherosclerotic process in blood vessels, leading to micro- and macro vascular complications, stroke being one of these. Carotid artery atherosclerosis in patients with Diabetic nephropathy is found to be associated with Silent cerebral infarction (SCI). Present study was carried to found any relationship between carotid intima media thickness and silent cerebral infarction in patients with type 2 diabetic nephropathy.Methods: The study was done in 50 DN patients admitted in medicine ward of tertiary care hospital. Subjects were evaluated based on detailed clinical data like symptoms, signs, and associated illnesses, general and systemic examination. Subjects were diagnosed with silent cerebral infarct based on MRI Findings. Each subject had undergone MRI to find out incidence of SCI.Results: Maximum (54%) was in age group of 61-70yrs and very few (6%) were below age of 50yrs. M: F was 1.6:1. Around 44% had duration of diabetes in 1-5yrs of duration and very few (6%) had diabetes >15yrs. On USG scan of carotid vessels it was found that 86% had increased carotid intimal media thickness either or side of vessel. On MRI brain there was incidence of silent cerebral ischemia among 30% study subjects.Conclusion: Both CIMT and SBI showed rise in incidence with corresponds to increase in age, duration of diabetes and urine albumin level among study subjects.

P1901Use of direct thrombin inhibitor on the day of atrial fibrillation ablation decreases incidence of silent cerebral ischemia detected by magnetic resonance imaging

Background There is increasing evidence to use direct oral anticoagulants (DOACs) in atrial fibrillation (AF) ablation. Uninterrupted use of DOACs is recommended for peri-procedural anticoagulation; the ways of choosing and/or using DOACs depend on physicians' decisions and preferences. Uninterrupted dabigatran (DAB), a direct thrombin inhibitor, reportedly decreased the risk of major bleeding (MB) in AF ablation, compared to uninterrupted warfarin (NEJM 2017; 376:1627). Among DOACs, only regular-dose of DAB (150 mg b.i.d.), showed superiority to warfarin for preventing ischemic thromboembolism (TE) in patients with non-valvular AF, implicating the powerful anti-thrombotic agent. DAB may decrease the potential risk of procedure-related TE. Purpose To evaluate whether use of DAB on the day of AF ablation decreases the prevalence of silent cerebral ischemia (SCI) detected by magnetic resonance imaging (MRI). Methods 414 AF patients on DOACs were enrolled and admitted on the day before AF ablation. Among 354 patients on factor Xa inhibitors (rivaroxaban, apixaban, and edoxaban), the original DOACs were switched to DAB (150 mg b.i.d.) on the day of the procedure in 172 patients (Group D); the treatment remained unchanged in 182 patients (Group non-D). In both groups, DOACs were continuously used throughout the procedure. After propensity-score matching, procedure-related parameters/events and the incidence of MRI-detected SCI were compared between Group D (n=134) and Group non-D (n=134). These parameters in patients originally taking DAB, used without interruption during the procedure (uninterrupted DAB, n=55), were also compared to Group D (n=55) after propensity-score matching. Results Baseline activated clotting time (ACT) before initial heparin injection was increased in Group D vs. Group-non-D (179±25* vs. 146±23 sec, *p<0.05 vs. Group non-D). The time to achieve optimal ACT (>300 sec) was shorter in Group D (34±29* vs. 43±32 min). The amounts of heparin needed to achieve optimal ACT and the total amount of heparin used during the procedure were unchanged between Group D and Group non-D. The incidence of SCI decreased in Group D (13.1%* vs. 21.9%), suggesting the potential anti-thrombotic efficacy of DAB. No MB or symptomatic TE events were observed in either group. Baseline ACT, the time to achieve ACT >300 sec, and the incidence of SCI in Group D were comparable to those in uninterrupted DAB (183±38 vs. 181±32 sec, 39±31 vs. 42±28 min, and 14.5% vs. 16.4%, respectively). No MB or symptomatic TE events were observed either in Group D or uninterrupted DAB. Conclusions Temporarily switching to DAB from the other DOACs and using it on the day of procedure enable us to achieve optimal ACT quickly and decrease the incidence of SCI, showing similar potential anti-thrombotic efficacy to uninterrupted DAB. Use of DAB on the day of AF ablation also benefits from the availability of its antidote in the case of MB during the procedure.

Diffusion weighted image documented cerebral ischemia in the postprocedural period following pipeline embolization device with shield technology treatment of unruptured intracranial aneurysms: a prospective, single center study

ObjectiveAcute ischemic stroke and silent cerebral infarctions following pipeline embolization device (PED) treatment of intracranial aneurysms have been estimated to occur in 3–6% and in 50.9–90% of patients respectively. The PED with Shield technology (PED-Shield) incorporates a surface phosphorylcholine polymer to reduce the thrombogenicity of the implant. We sought to determine the incidence of diffusion weighted image (DWI) documented cerebral ischemia after PED-Shield treatment of unruptured intracranial aneurysms.MethodsThis prospective study involved a single center series of consecutive patients treated for an unruptured intracranial aneurysm with the PED-Shield. All participants underwent clinical evaluation on admission, after the procedure, at discharge, and 30 days following treatment. Brain MRI was obtained within 72 hours of the procedure. Ischemic lesions identified on DWI sequences where examined as to their number, size, and location in relation to the procedure.ResultsOver 12 months, 33 patients harboring 38 intracranial aneurysms were treated with the PED-Shield in 36 procedures. Neither mortality nor clinically evident ischemic events were noted in the 30 day postprocedural period. DWI documented, silent cerebral ischemia occurred in six patients (18.18%) after six procedures (16.66%). No statistically significant risk factors for postprocedural silent cerebral ischemia were identified.ConclusionWe demonstrated a reduced rate of silent cerebral infarcts following PED-Shield treatment of intracranial aneurysms than previously reported with other endovascular treatment modalities and with the previous device generations. Further research is necessary to evaluate our results and to identify methods to reduce the incidence of postprocedural cerebral ischemic events.