Cerebrovascular events in COVID-19 patients

Neurological manifestations in patients with COVID-19 are more frequently being reported. Cerebrovascular events have been reported in around 3% of patients. In this review we summarize the published literature on cerebrovascular events in patients with COVID-19 as available on the PubMed database. So far, 3 studies have reported cerebrovascular events. Cerebrovascular events were identified on screening patients with decreased consciousness or in the presence of focal neurological deficits. These events were common in elderly, critically ill patients and in patients with prior cardio-cerebrovascular comorbidities. The diagnosis of cerebrovascular events was confirmed with computed tomography of the brain in most studies reporting neurological events. Multiple pathological mechanisms have been postulated regarding the process of neurological and vascular injury among which cytokine storm is shown to correlate with mortality. Patients with severe illness are found to have a higher cardio- cerebrovascular comorbidity. With an increasing number of cases and future prospective studies, the exact mechanism by which these cerebrovascular events occur and attribute to the poor outcome will be better understood

Carotid endarterectomy : the Maltese experience

Introduction: Carotid endarterectomy significantly reduces the risk of cerebrovascular events in both symptomatic and asymptomatic patients with significant carotid stenosis. The recent American Heart Association/American College of Cardiology guidelines advise that carotid endarterectomy is only beneficial when the perioperative stroke or mortality rate is below 6%. The aim of this study was to review the results of carotid endarterectomy performed in Malta by one vascular surgeon. Methods: All patients undergoing carotid endarterectomy between July 2007 and June 2011 were included in the study. Data was entered prospectively into a vascular database. Retrospective review of the case notes of all patients undergoing carotid endarterectomy was also performed. Demographics of the patient cohort as well as information about perioperative mortality, cerebrovascular events, cardiac events as well as any other complications were recorded. Information was also collected about any deaths and cerebrovascular events during the follow up period. Results: 51 patients underwent carotid endarterectomy during the study period. 94% were symptomatic (65% CVA; 15% TIA; 10% amaurosis fugax; 4% TIA and amaurosis) and 6% asymptomatic. 46% had an internal carotid artery stenosis of 90% or more while the rest had a stenosis of 70% or more. 31% of patients also had significant contralateral carotid stenosis or occlusion. There was one postoperative mortality (1.9%) and one patient sustained a postoperative lacunar stroke (1.9%). There were no cranial nerve injuries and no bleeding requiring return to theatre. The combined perioperative mortality and stroke rate in this cohort was 3.9%. Conclusions: The combined perioperative mortality and stroke rate in this sutdy is better than that reported in the major randomised controlled trials. The perioperative death and stroke rate is well below the threshold level advised by the AHA/ACC.peer-reviewe

Treatment of thyroid dysfunctions decreases the risk of cerebrovascular events in men but not in women: results of the MONICA/KORA Cohort Study

OBJECTIVE:Thyroid disorders are well known to be associated with cardiovascular diseases. Some studies have shown that the negative effects of thyroid disorders are partially reversible after adequate treatment. The aim of this analysis was to assess the risk of incident ischemic cerebrovascular diseases in study participants treated for thyroid dysfunctions in a population-based cohort study. METHODS:For the presented analyses data from 8564 male and 8714 female individuals aged 25 to 74 years of the MONICA/KORA cohort were used (median follow-up 14.0 years). A combined binary variable "thyroid disorder" (TDC) was created utilizing data on self-reported physician-treated thyroid disorders and information about medication use. To examine the association between TDC and incident ischemic cerebrovascular events, we performed multiple adjusted Cox proportional hazard regression models and calculated hazard ratios and corresponding 95% confidence intervals (HR, 95%CI). RESULTS:During follow-up between 1984 and 2008/2009, 514 incident fatal and non-fatal ischemic cerebrovascular events occurred in men and 323 in women. At baseline, 3.5% of men and 15.6% of women reported TDC. In the fully adjusted model, males who reported TDC had a significantly reduced risk of ischemic cerebrovascular events (HR = 0.52, 95%CI = 0.29-0.92). A similar result was obtained in men, when we utilized information on thyroid hormones use only. For the total study population and for women with TDC we found no association with ischemic cerebrovascular events. CONCLUSIONS:In our longitudinal analyses subjects with treated thyroid diseases had no increased risk of incident ischemic cerebrovascular events. Surprisingly in males, even a significantly reduced risk of incident ischemic cerebrovascular events was found, a result that deserves further clarification

Myasthenia Gravis Mimicking Acute Cerebrovascular Events

Background and Objective: Myasthenia gravis (MG) is an immune-mediated disorder that can sometimes present acutely with a focal neurological deficit and thus mimic a cerebrovascular event. The objective of this study was to describe the clinical characteristics in a large cohort of patients who were initially misdiagnosed with an acute vascular event and later diagnosed with MG. Methods: This is a retrospective chart review of patients who were initially diagnosed with an acute cerebrovascular event but subsequently found to have MG. The chart review was done for the period from January 2013 to December 2017, and patients with at least one-year follow-up included.  Data are reported as means ± SEM, and the results reported using prevalence rates. Results: Twenty-one patients met our inclusion criteria. Among them, 13 (61.9%) were female with a mean age of 56.7 ± 4.07 years. Ten were MGFA class 3a; seven were MGFA class 2b, 3 were MGFA 3b. Eighteen patients were acetylcholine receptor antibody positive; one was MuSK positive, and the rest two seronegative. Slurred speech (8 patients, 38.1%) was the most common symptom that resulted in misdiagnosis, followed by hemibody weakness (7 patients, 33.3%) and dysphagia (3, 14.3%). Smoking (12, 57.1%) and hypertension (11, 52.4%) were common risk factors for cerebrovascular disease. Small vessel disease was suspected the most common etiology (15, 71.4%) of the vascular event.  Ten patients had received thrombolytic therapy, and 16 patients were on antiplatelets. 4 patients who presented recurrent symptoms placed on anticoagulants. Conclusion: Acute presentation of bulbar symptoms and hemibody weakness resulted in the misdiagnosis of MG

Recurrence in intracranial atherosclerotic disease: a stenosis-based analysis

BACKGROUND: Intracranial atherosclerotic disease is a common cause of stroke; its incidence and prevalence vary widely by ethnicity. The aim of our study was to analyze the recurrence rate of cerebrovascular events in patients with symptomatic and asymptomatic intracranial stenosis (IS). METHODS: We conducted a historical cohort study including all patients admitted in our hospital for stroke or transient ischemic attack (TIA) during 2011 and 2012 with information on intracranial circulation (ultrasonography and/or computed tomography angiography). We identified patients with symptomatic and asymptomatic IS and studied the recurrence of cerebrovascular events (TIA or ischemic stroke within the territory of the stenosis) for a minimum follow-up period of 6 months after the diagnosis of IS. For the recurrence rate estimation, patients with other potentially embolic diseases (in cervical arteries or heart) were excluded. We calculated the rate of recurrence of cerebrovascular events and performed Kaplan-Meier survival curves for symptomatic and asymptomatic IS. RESULTS: We investigated 1302 patients, mean age was 72.41 years (standard deviation 12.75). We identified 218 IS in 158 patients, 77 were symptomatic and 141 were asymptomatic. The recurrence rate of cerebrovascular events was 12.32 per 100 patient-years, with a mean time to recurrence of 1.73 months for symptomatic intracranial stenosis (SIS) and .88 per 100 patient-years for asymptomatic IS (P < .001). CONCLUSIONS: These results indicate a high risk of early recurrence of stroke in the territory of a SIS, highlighting the importance of its early diagnosis and aggressive treatment.info:eu-repo/semantics/publishedVersio

Imaging Carotid Atherosclerosis Plaque Ulceration: Comparison of Advanced Imaging Modalities and Recent Developments.

Atherosclerosis remains the leading cause of long-term mortality and morbidity worldwide, despite remarkable advancement in its management. Vulnerable atherosclerotic plaques are principally responsible for thromboembolic events in various arterial territories such as carotid, coronary, and lower limb vessels. Carotid plaque ulceration is one of the key features associated with plaque vulnerability and is considered a notable indicator of previous plaque rupture and possible future cerebrovascular events. Multiple imaging modalities have been used to assess the degree of carotid plaque ulceration for diagnostic and research purposes. Early diagnosis and management of carotid artery disease could prevent further cerebrovascular events. In this review, we highlight the merits and limitations of various imaging techniques for identifying plaque ulceration

Assessing the effect of statins in lowering the risk of stroke and preventing cerebral ischemia in patients with hypercholesterolemia

Numerous analyses have explored the role of statins in reducing stroke incidence, reducing cerebral ischemia in hypercholesterolemic patients, and preventing ischemic stroke. This paper aims to assess the effect of statins in lowering the risk of stroke and preventing cerebral ischemia in patients with hypercholesterolemia. To achieve this objective, the literature was reviewed, randomized control tests were analyzed, and a systematic review was performed. The risk of developing cerebral ischemia was found to be reduced in hypercholesterolemic patients and patients with a history of cerebrovascular disease. However, it is unknown whether this reduction in incidence is a result of the drug, which reduces low-density lipoprotein levels in the blood, or to statins’ pleotropic effects on the vascular endothelium. Since their discovery, statins have proven to be beneficial in controlling cholesterol blood levels. Moreover, statins have been shown to have pleotropic effects after a certain period of use, one of which is lowering ischemic stroke incidence in hypercholesterolemic patients. Most recently, statins have been found to lower systolic blood pressure. It is not yet clear whether it has a significant effect on mortality or whether or not it is linked to statins

Fabry disease: progression of nephropathy, and prevalence of cardiac and cerebrovascular events before enzyme replacement therapy

Background. In Fabry disease, progressive glycolipid accumulation leads to organ damage and early demise, but the incidence of renal, cardiac and cerebrovascular events has not been well characterized

Blood pressure, Severity of Stroke and Preventive Effects of Antihypertensive Therapy in Patients with Asymptomatic Internal Carotid Artery Stenosis - Is blood pressure and antihypertensive therapy associated with outcomes of stroke?

Introduction: Even though blood pressure (BP) lowering is important in the primary and secondary prevention of stroke, intensive BP lowering might be deleterious in some patients with asymptomatic carotid artery stenosis (ACAS). The optimal BP target for patients with ACAS is unknown. There are currently no studies showing the relationship between blood pressure and functional outcome of stroke in patients with ACAS. Our aim is to assess the relationship between systolic blood pressure (SBP), stroke and functional outcome of ischemic stroke (IS), in addition to possible protective effects of specific antihypertensive therapy. Materials and methods: Patients with significant stenosis of the internal carotid artery with no prior history of cerebrovascular events were included. Electronic patient journals were individually searched, and clinical and biochemical characteristic were collected. Primary endpoints of cerebrovascular events, IS, transient ischemic attack (TIA) and favorable outcome of stroke were registered. Univariate analysis was performed using χ2 or independent t-test for percentages and continuous variables, respectively. Potential confounders were initially inserted into the logistical regression model and subsequently removed by backward stepwise selection Results: A total of 286 patients were included in this study. SBP was associated with increased risk of cerebrovascular events (OR, 1.013; 95% CI, 1.002 - 1.024; p, 0.017) and IS (OR, 1.018; 95% CI, 1.005 - 1.032; p, 0.009). SBP was positively associated with favorable outcome of IS (OR, 1.032; 95% CI, 1.003 - 1.061; p, 0.028). Patients using calcium channel blockers (CCB) had a significantly lower risk of TIA (p=0.016). Conclusion: This study suggests that SBP is associated with combined cerebrovascular events and IS. In addition, SBP is proportionally associated with good functional outcome after IS. A significantly lower incidence of TIA was observed among patients using CCBs