Multiple Vascular Accidents Including Rupture of a Sinus of Valsalva Aneurysm, a Minor Ischemic Stroke and Intracranial Arterial Anomaly in a Patient with Systemic Congenital Abnormalities: A Case Report

A 39-year-old man with a history of rupture of a sinus of Valsalva aneurysm experienced an ischemic stroke. Although the patient presented left-sided hemiparesis for a week, no abnormal signals were indicated on diffusion-weighted imaging with repeated magnetic resonance scans. Carotid ultrasound and cerebral angiography were conducted, and they revealed hypoplasty of the left internal carotid artery with a low-lying carotid bifurcation at the level of the C6 vertebra. In addition, he was diagnosed with intellectual disabilities, evaluated by the Wechsler Adult Intelligence Scale-III, and congenital velopharyngeal insufficiency. We herein present the first report of a patient with cardio-cerebrovascular abnormalities, intellectual disabilities, and an otorhinolaryngological abnormality

Imaging Indicators for Parenchymal Hemorrhage After Mechanical Thrombectomy in Acute Stroke

Background In patients with acute ischemic stroke with large vessel occlusion, the presence of hyperintense lesions on fluid‐attenuated inversion recovery (FLAIR‐positive) before mechanical thrombectomy (MT) and that of hyperdense lesions on noncontrast computed tomography (CT‐positive) after MT are associated with parenchymal hemorrhage, but the significance of these findings is unclear. Methods Patients with acute stroke with large vessel occlusion underwent magnetic resonance imaging, including diffusion‐weighted imaging and FLAIR, before MT. Noncontrast CT was obtained within 60 minutes after MT. The occurrence of parenchymal hemorrhage type 2 (PH2) was assessed on CT within 7 days after MT. FLAIR and CT‐positive were defined as a case with hyperintense and hyperdense lesions immediately before and after MT, respectively. Clinical and imaging factors associated with PH2 were evaluated by multivariate regression analysis. Results Enrolled were 412 patients (median age, 76 years; men, 58.3%; median National Institutes of Health Stroke Scale score, 16). The site of occlusion was the internal carotid artery (n=122, 29.6%), M1 (n=180, 43.7%), and M2 (n=96, 23.3%). FLAIR‐positive, CT‐positive, and PH2 were found in 149 (36.2%), 223 (54.1%), and 34 patients (8.3%), respectively. PH2 was significantly more frequent in CT‐positive than CT‐negative patients (14.3% versus 1.1%; P<0.001), but not in FLAIR‐positive than FLAIR‐negative patients (10.7% versus 6.8%; P=0.193). Regardless of FLAIR status, PH2 was significantly more frequent in CT‐positive than CT‐negative patients (12.8% versus 0.8% [P<0.001] for FLAIR‐negative, and 16.7% versus 1.7% [P=0.003] for FLAIR‐positive). Multivariate regression analysis demonstrated that CT‐positive was the only independent factor associated with PH2 (odds ratio, 12.699 [95% CI, 2.964–54.416]; P<0.001). Sensitivity, specificity, positive predictive value, and negative predictive values of CT‐positive for predicting PH2 occurrence were 94.1%, 49.5%, 14.3%, and 98.9%, respectively. Conclusion In patients with acute ischemic stroke with large vessel occlusion, CT‐positive immediately after MT was strongly predictive of PH2, but no such relationship was found for FLAIR‐positive before MT

Detection of Atrial Fibrillation Using Insertable Cardiac Monitors in Patients With Cryptogenic Stroke in Japan (the LOOK Study): Protocol for a Prospective Multicenter Observational Study

BackgroundParoxysmal atrial fibrillation (AF) is a probable cause of cryptogenic stroke (CS), and its detection and treatment are important for the secondary prevention of stroke. Insertable cardiac monitors (ICMs) are clinically effective in screening for AF and are superior to conventional short-term cardiac monitoring. Japanese guidelines for determining clinical indications for ICMs in CS are stricter than those in Western countries. Differences between Japanese and Western guidelines may impact the detection rate and prediction of AF via ICMs in patients with CS. Available data on Japanese patients are limited to small retrospective studies. Furthermore, additional information about AF detection, including the number of episodes, cumulative episode duration, anticoagulation initiation (type and dose of regimen and time of initiation), rate of catheter ablation, role of atrial cardiomyopathy, and stroke recurrence (time of recurrence and cause of the recurrent event), was not provided in the vast majority of previously published studies. ObjectiveIn this study, we aim to identify the proportion and timing of AF detection and risk stratification criteria in patients with CS in real-world settings in Japan. MethodsThis is a multicenter, prospective, observational study that aims to use ICMs to evaluate the proportion, timing, and characteristics of AF detection in patients diagnosed with CS. We will investigate the first detection of AF within the initial 6, 12, and 24 months of follow-up after ICM implantation. Patient characteristics, laboratory data, atrial cardiomyopathy markers, serial magnetic resonance imaging findings at baseline, 6, 12, and 24 months after ICM implantation, electrocardiogram readings, transesophageal echocardiography findings, cognitive status, stroke recurrence, and functional outcomes will be compared between patients with AF and patients without AF. Furthermore, we will obtain additional information regarding the number of AF episodes, duration of cumulative AF episodes, and time of anticoagulation initiation. ResultsStudy recruitment began in February 2020, and thus far, 213 patients have provided written informed consent and are currently in the follow-up phase. The last recruited participant (May 2021) will have completed the 24-month follow-up in May 2023. The main results are expected to be submitted for publication in 2023. ConclusionsThe findings of this study will help identify AF markers and generate a risk scoring system with a novel and superior screening algorithm for occult AF detection while identifying candidates for ICM implantation and aiding the development of diagnostic criteria for CS in Japan. Trial RegistrationUMIN Clinical Trial Registry UMIN000039809; https://tinyurl.com/3jaewe6a International Registered Report Identifier (IRRID)DERR1-10.2196/3930