The Clinical Outcomes of Ventricular Septal Rupture Secondary to Acute Myocardial Infarction: A Retrospective, Observational Trial

Background. Ventricular septal rupture (VSR) is a severe mechanical complication secondary to acute myocardial infarction (AMI) with a dreadful prognosis. The goal of our study was to evaluate the mortality and to identify the predictors of mortality for this population. Methods. From June 2012 to July 2021, patients with VSR secondary to AMI were initially screened for eligibility in this study. The potential risk predictors were determined using appropriate logistic regression models. Results. In this retrospective study, a total of 50 cases were included, and 14 patients survived and got discharged successfully. Univariable analyses indicated that the heart rate (HR), white blood cell (WBC) count, neutrophils count, serum glucose, serum creatinine, serum lactic acid, and the closure of rupture were significantly associated with mortality among these special populations. Conclusion. This study found that such high mortality in patients with VSR after AMI was significantly correlated with these risk factors representing sympathetic excitation and large infarct size. Coronary revascularization combined with the closure of rupture might be helpful in improving their prognosis.

Faktor Faktor Risiko terjadinya Pneumonia pada Stroke Akut di RSUP Dr Hasan Sadikin Bandung

Risk Factors of Pneumonia in Acute Stroke at Hasan Sadikin Hospital Bandung Abstract Background and Objective:Pneumonia is the most common non neurological complications in acute stroke (22%) that increase mortality rate, length of stay and hospitalization cost. It is necessary to identified risk factors for pneumonia including neurogenic pulmonary edema (NPE) for better prevention and early intervention. The purpose of this study is to determine risk factors of pneumonia (including NPE) in acute stroke patients at Hasan Sadikin General Hospital Bandung. Subject and Methods: Prospective observational descriptive study, consecutive sampling method, during September – October 2019. Primary data collected from acute stroke patients such as stroke severity, type, location and size of stroke, treatment during hospitalizataion, comorbidities (including NPE). Pneumonia was diagnosed based on Central for Disease Control Prevention (CDC) criteria, NPE based on Davison criteria. Results: 30 patients (28.3%) with pneumonia in acute stroke patients. Pneumonia were commonly found in NGT insertion (90%), dysphagia (64,71%), total anterior circulation infarct (TACI) (61,54%), large infarct size (61,54%), GCS 9-12 (50%) and NIHSS 16-20 (50%). NPE only found in 6,60% acute stroke patients, 57,14% of them developed pneumonia. Conclusions: Pneumonia in acute stroke patients is more often found in NGT insertion, dysphagia, TACI location, large infarct size, lower GCS and more severe stroke degree.

Ischemic Stroke in Patients with COVID-19 Disease: A Report of 10 Cases from Iran

Ischemic stroke seems to be one of the most serious neurologic complications in patients with COVID-19 infection. Herein, we report a series of 10 ischemic stroke patients with concomitant COVID-19 disease. Out of 10, 8 had large infarcts (3 massive middle cerebral artery, 2 basilar artery, 2 posterior cerebral artery, and 1 internal carotid artery infarct territory). Two had cardiogenic embolic stroke due to atrial fibrillation. Almost half of our patients did not have a vascular risk factor. Nine did not have fever and were diagnosed with COVID-19 upon admission for stroke. Stroke occurred in the first week of respiratory symptoms with moderate pulmonary involvement. Most Patients did not have hypoxia and did not establish respiratory failure or acute respiratory distress syndrome. The blood pressures were low and hemorrhagic transformation did not occur even after antiplatelet or anticoagulant therapy. Patients had markedly increased levels of lactate dehydrogenase, C-reactive protein, and D-dimer. Three patients died. It seems that ischemic strokes in COVID-19 patients tend to occur as large infarct and can be seen in patients with mild to moderate pulmonary involvement.

Reliability of Clinical DWI Mismatch Approach to Predict Patient With the Probability of Large Infarct Growth: A Comparison of the Percentage of Infarct Growth and Clinical DWI Mismatch Status of the Patients With Acute Ischemic Stroke

Purpose: The purpose of this study is to highlight the reliability of clinical DWI mismatch (CDM) in the identification of patients with large infarct growth. Methods: We prospectively reviewed 21 ischemic stroke patients who underwent DWI imaging within 72 hours from stroke symptoms onset. Description of images was made by experienced radiologists. Lesion volumes were assessed by manually outlining the DWI infarct lesions area. The percentage of infarct growth was calculated by dividing the difference between second and first infarct volume by the first infarct volume times 100. The NIHSS scores were assessed by an experienced neurologist. CDM was defined as NIHSS score ≥8 and initial infarct volume on DWI ≤ 25 mL. Statistical Tests: We assessed the relationships of variables within different groups of CDM using nonparametric tests—Kruskal-Wallis and chi-square test. Sensitivity and specificity of CDM to predict large infarct growth were tested by using crosstabs table. Results: CDM was present in 36.8% of our patients and was associated with the percentage of infarct growth ( P < .01). The mean percentage growth was high in patients with CDM (211.8%) while it was low in the group of patients without CDM (5.7%; group B and 10.7%; group C). The sensitivity and specificity of CDM to predict infarct growth was 77.8% vs 100% with a likelihood ratio of 15.4 ( P = .0004). Conclusion: The approach of comparing CDM and percentage of infarct growth proved that the concept of CDM can accurately indicate the existence of a large volume of tissue at risk of infarction—penumbra.

Perfusion Imaging to Select Patients with Large Ischemic Core for Mechanical Thrombectomy

Background and Purpose Patients with acute ischemic stroke, proximal vessel occlusion and a large ischemic core at presentation are commonly not considered for mechanical thrombectomy (MT). We tested the hypothesis that in patients with baseline large infarct cores, identification of remaining penumbral tissue using perfusion imaging would translate to better outcomes after MT.<br/>Methods This was a multicenter, retrospective, core lab adjudicated, cohort study of adult patients with proximal vessel occlusion, a large ischemic core volume (diffusion weighted imaging volume ≥70 mL), with pre-treatment magnetic resonance imaging perfusion, treated with MT (2015 to 2018) or medical care alone (controls; before 2015). Primary outcome measure was 3-month favorable outcome (defined as a modified Rankin Scale of 0–3). Core perfusion mismatch ratio (CPMR) was defined as the volume of critically hypo-perfused tissue (Tmax >6 seconds) divided by the core volume. Multivariable logistic regression models were used to determine factors that were independently associated with clinical outcomes. Outputs are displayed as adjusted odds ratio (aOR) and 95% confidence interval (CI).<br/>Results A total of 172 patients were included (MT n=130; Control n=42; mean age 69.0±15.4 years; 36% females). Mean core-volume and CPMR were 102.3±36.7 and 1.8±0.7 mL, respectively. As hypothesized, receiving MT was associated with increased probability of favorable outcome and functional independence, as CPMR increased, a difference becoming statistically significant above a mismatch-ratio of 1.72. Similarly, receiving MT was also associated with favorable outcome in the subgroup of 74 patients with CPMR >1.7 (aOR, 8.12; 95% CI, 1.24 to 53.11; P=0.028). Overall (prior to stratification by CPMR) 73 (42.4%) patients had a favorable outcome at 3 months, with no difference amongst groups.<br/>Conclusions In patients currently deemed ineligible for MT due to large infarct ischemic cores at baseline, CPMR identifies a subgroup strongly benefiting from MT. Prospective studies are warranted.

Radiological Findings By Magnetic Resonance (MRI) and Arteriography (MRA) Brain Imaging Compared to Neurological, Stroke and TCD Assessment in Children with Sickle Cell Anemia in Uganda

Background: Children with sickle cell anemia (SCA) are highly susceptible to stroke and other manifestations of pediatric cerebral vasculopathy. Detailed evaluations of children with SCA in sub-Saharan Africa are limited, especially magnetic resonance imaging and angiography (MRI/MRA). In a sample of Ugandan children receiving care at the Mulago Hospital sickle cell clinic in Kampala and were not on disease-modifying therapy, we examined the range of MR imaging findings, and how those findings correlated with standardized demographic, clinical, neurological and neurocognitive assessments. Methods: From within a larger sample of 265 participants with HbSS ages 1-12 years not taking disease-modifying therapy and enrolled in the BRAIN SAFE study, a sub-sample of 81 underwent non-contrast MRI/MRA on a 1.5 Telsa scanner. Participants also underwent 3 standardized assessments: neurocognitive testing by experienced testers using the Mullen Scales of Early Learning (for ages 1-4 years) or Kaufman Assessment Battery for Children, 2nd edition (for ages 5-12) (abnormal z-score of -2 or lower), stroke examination (PedsNIHSS) and transcranial Doppler ultrasound (TCD) using criteria for pediatric SCA. Participants undergoing MRI/MRA intentionally included 29 without any abnormal findings. MRI scans included T1- and T2- weighted images, T2 FLAIR and MRA three-dimensional time-of-flight technique. MR scans were interpreted by clinical and research methods, the latter per SWiTCH protocol (Helton, Blood 2014). Adjudication of differing reads was performed by a blinded third neuroradiologist. Results: A total of 81 children with SCA were examined by MRI/MRA. Mean age was 6.48 ± 2.75 years; 50.6% were male. Mean hemoglobin was 7.26±0.90 g/dl; 75% had hemoglobin <8.0. In all, 16.7% were malnourished using standard international measures established by age and sex. Infarcts and/or arterial stenoses on MRI/MRA were detected in 42 (52%), including 13 (25%) with no other abnormalities detected. There were 35 children (43.2%) who had medium or large infarcts seen; an additional 16 (19.8%) had 1-2 small infarcts. Four had moya moya. Of the 29 children categorized as normal on each of the 3 other tests, 14 (48.3%) had one or more medium or large infarct(s) on MRI, and 3 (10.3%) had 1-2 small infarcts (Figure 1). The proportion of children with malnutrition was higher among those with an abnormal MRI compared to those with a normal MRI, whereas no children with a small infarct was malnourished (29.4% vs. 10.7% vs. 0% p=0.019). A higher proportion of participants with stroke by exam had medium or large infarct(s) compared to participants with normal or small infarct (28.6% vs. 10% vs. 6.3%; p=0.061). Stroke on exam was associated with medium or large infarct(s) compared to normal or small infarct (unadjusted OR 4.2; 95% CI 1.19-14.8), and remained after adjusting for age and hemoglobin (OR 3.90 95%CI 1.10-13.9). The proportion of abnormal psychological testing was higher in the small infarct group than in the group with larger infarct(s) or the normal group (37.5% vs. 28.6% vs. 17.2%; p=0.307). Conclusion: High prevalence of pediatric cerebral vasculopathy was found on MR scanning. Despite clinical evidence suggesting abnormal neuropsychological testing or a prior stroke, not all of the children who had clinical evidence of neurological disorders had MRI evidence of a stroke. Additionally, a number with no evidence of stroke had infarct(s) on MRI, so-called "silent stroke." The strongest predictors of an abnormal MRI reading included having a detectable stroke or an abnormal TCD. MR imaging is a critical aspect of evaluating cerebral vasculopathy in this patient population, and will be an important measure when prospectively assessing impact in a treatment trial. Disclosures No relevant conflicts of interest to declare.