Bi-atrial thrombus causing embolic stroke and pulmonary embolisms

Objective: To present a rare case of bi-atria thrombus that caused embolic stroke and PE and was treated with emergent embolectomy. Background: Right atriumthrombus is labeled as thrombi in transit. It either progresses to the pulmonary arteries causing significant pulmonary embolism, or it straddles through Foramen Ovale leading to impending paradoxical embolism causing ischemic strokes. We are presenting a rare case of right atrial thrombi straddling through PFO and causing embolic ischemic stroke and multiple PEs. Results: A 79 years old male with history of coronary artery disease s/p CABG surgery who presented with acute onset altered mental status and left side weakness. CT angiogram of the head showed occlusion of the distal right posterior cerebral artery PCA. Brain MRI confirmed the acute right occipital lobar infarct. Transthoracic and transesophageal echocardiogram confirmed the right atrium, 5.5 x 0.7 cm serpentine thrombus extending across PFO to the left atrium and relapsing through the mitral valve. CT PE showed pulmonary emboli in the proximal left lower pulmonary artery and the segmental and subsegmental branches. This raised the concern for anterograde propagation of the right atrial thrombus into the pulmonary artery. The patient remained hemodynamically stable with neurological deficit of left homonymous hemianopsia and left ataxia. Given the size and burden of the thrombus and the risk of further embolization, patient was started on IV anticoagulation. He underwent emergent percutaneous right atrial aspiration embolectomy followed by endovascular closure of the PFO. The patient improved without further strokes. Conclusion: Treatment of bi-atrial intra-cardiac thrombus causing both systematic and pulmonary embolization is not yet standardized. However, due to high risk of systematic embolization especially embolic stroke, acute intervention with embolectomy is favored. PFO closure has been shown in multiple clinical trials to decrease risk of paradoxical stroke. This is a case of multi-systemic embolization of the bi-atrial thrombus showing favored outcome with immediate intervention with concurrent anticoagulation.https://scholarlycommons.henryford.com/merf2020caserpt/1015/thumbnail.jp

Terson’s Syndrome: An Underdiagnosed Complication of Subarachnoid Hemorrhage

Background: Terson Syndrome refers to an intraocular hemorrhage in patients with severe subarachnoid hemorrhage (SAH), traumatic brain injury or intracerebal hemorrhage. The mechanism of injury is due to increased intracranial pressure which transmits into the optic nerve sheath and causes rupture of the retinal vessels. Despite its relatively common incidence, the syndrome remains under diagnosed or delayed because it usually occurs in severely ill patients with depressed level of consciousness. Early recognition of the intraocular hemorrhage on head CT and treatment can be significant to patient\u27s outcome. Case Description: We present a 46-year-old man with a past medical history of excessive EtOH use who presented to the emergency department with sudden onset of severe headache, nausea, and brief loss of consciousness. He acutely decompensated with tonic clonic seizure associated with hypertension, tachycardia, and vomiting. A stat head CT revealed subarachnoid hemorrhage involving the perimesencephalic cisterns, intraventricular hemorrhage, and hydrocephalus. CT Angiography revealed a left vertebral artery V4 dissecting-type aneurysm. Hunt and Hess Scale score was 2 and modified Fisher score was 4. An external ventricular drain (EVD) was inserted by Neurosurgery and he underwent cerebral angiography with deployment off low-diverting stent in the left vert V4 dissecting aneurysm. After extubation, the patient was complaining of bilateral blindness. Examination revealed inability to track movements, or blink to threat. It was believed that the vision loss was due to a bilateral posterior cerebral arteries (PCA) strokes versus manifestation of acute encephalopathy. Ophthalmology was consulted and fundus exam revealed bilateral vitreous and subhyaloid hemorrhages, concerning for Terson Syndrome. The patient underwent right eye pars plana vitrectomy for intraocular pressure relief. Retrospective review of head CT from admission showed bilateral crescentic hyperdensity in the posterior vitreous that is consistent with the diagnosis of Terson syndrome. Conclusion: This case sheds light on the importance of early recognition of Terson Syndrome as a possible complication of sever SAH especially with high Hunt and Hess and Fischer scale scores as well as tell-tale signs of elevated intracranial pressure. In majority of cases, the syndrome remains undiagnosed in the early phase due to severity of patient’s illness and delayed clinical complaint of vision loss. This leads to delay in appropriate treatment and ultimately endangers patient\u27s vision. In patients with severe subarachnoid hemorrhage, careful review of head CT for intraocular crescentic hyperdensity can prompt an early diagnosis of Terson Syndrome.https://scholarlycommons.henryford.com/merf2020caserpt/1039/thumbnail.jp

Single-centre study surveying neurology trainees\u27 and faculty\u27s perceptions of the impact of the COVID-19 pandemic on residents\u27 medical education

Objective: To assess perceptions of our neurology residents and faculty regarding training experience and medical education during the early COVID-19 pandemic. Methods: We distributed two online, voluntary and anonymous surveys to trainees and teaching faculty of our Neurology Department at Henry Ford Hospital. Surveys inquired about trainees\u27 stress, well-being, clinical experience and satisfaction with medical education and available support resources during the first wave of the COVID-19 pandemic in Michigan (mid-March to June 2020). Results: A total of 17/31 trainees and 25/42 faculty responded to the surveys. Eight (47%) trainees reported high stress levels. Nine (57%) were redeployed to cover COVID-19 units. Compared with non-redeployed trainees, redeployed residents reported augmented medical knowledge (89% vs 38%, p=0.05). There was no difference in the two groups regarding overall satisfaction with residency experience, stress levels and didactics attendance. Twenty-one (84%) faculty felt that the redeployment interfered with trainees education but was appropriate, while 10 (59%) trainees described a positive experience overall. Both trainees and faculty believed the pandemic positively impacted trainees\u27 experience by increasing maturity level, teamwork, empathy, and medical knowledge, while both agreed that increased stress and anxiety levels were negative outcomes of the pandemic. Twelve (70%) trainees and 13 (52%) faculty were interested in pursuing more virtual didactics in the future. Conclusion: Our findings provide an objective assessment of residents\u27 experience during the COVID-19 pandemic and can guide teaching programmes in their medical education response in the face of future global crises

Cardioembolic stroke caused by bi-atrial thrombus and treated with intracardiac thrombectomy; a case report

Background: Right atrium thrombus is labeled as thrombi in transit. It either progresses to the pulmonary arteries causing significant pulmonary embolism, or it straddles through Foramen Ovale leading to impending paradoxical embolism causing ischemic strokes. We are presenting a rare case of right atrial thrombi straddling through PFO and causing embolic ischemic stroke and multiple PEs. Results: A 79 years old male with history of coronary artery disease s/p CABG surgery who presented with acute onset altered mental status and left side weakness. CT angiogram of the head showed occlusion of the distal right posterior cerebral artery PCA. Brain MRI confirmed the acute right occipital lobar infarct. Transthoracic and transesophageal echocardiogram confirmed the right atrium, 5.5 x 0.7 cm serpentine thrombus extending across PFO to the left atrium and relapsing through the mitral valve. CT PE showed pulmonary emboli in the proximal left lower pulmonary artery and the segmental and subsegmental branches. This raised the concern for anterograde propagation of the right atrial thrombus into the pulmonary artery. The patient remained hemodynamically stable with neurological deficit of left homonymous hemianopsia and left ataxia. Given the size and burden of the thrombus and the risk of further embolization, patient was started on IV anticoagulation. He underwent emergent percutaneous right atrial aspiration embolectomy followed by endovascular closure of the PFO. The patient improved without further strokes. Conclusions: Treatment of bi-atrial intra-cardiac thrombus causing both systematic and pulmonary embolization is not yet standardized. However, due to high risk of systematic embolization especially embolic stroke, acute intervention with embolectomy is favored. PFO closure has been shown in multiple clinical trials to decrease risk of paradoxical stroke. This is a case of multi-systemic embolization of the bi-atrial thrombus showing favored outcome with immediate intervention with concurrent anticoagulation

Novel Iron-Targeted Therapy Is Highly Effective in Treatment-Resistant High-Grade Glioma in Vivo

BACKGROUND: Chemo-and radioresistance are characteristic features of post-treatment high-grade glioma (HGG). The cell populations responsible for this treatment-resistant phenotype are glioma stem cells (GSCs). These GSCs have a high requirement for iron which is essential for tumor cell viability. Intriguingly, the transferrin receptors that play a crucial role in iron uptake by both adult and pediatric astrocytomas exhibit a high affnity for gallium maltolate (GaM), a novel iron mimetic. Given the added commonality between adult and pediatric glioma stem cell signatures, especially post-treatment, we believe targeting treatment-resistant cell populations via their inherent iron metabolism is a viable approach to combat treatment-resistant HGG in adults and children. Here, we demonstrate the profound effects of GaM in a novel in vivo model of recurrent glioblastoma. METHODS: Irradiated human GBM cells (adult or pediatric) were stereotactically implanted into the right striatum of male athymic rats. Following confrmation of in vivo tumor growth by MRI at 9.4T, animals received GaM (50 mg/kg/day) in an oral preparation for voluntary ingestion. Tumor growth was monitored weekly by MRI, and lesion volume and associated advanced MRI parameter maps were determined using enhancing tumor ROIs. RESULTS: In a first set of animals, the mean weekly tumor growth rates of enhancing lesions were 65.8% and 156% in GaM-treated and control rats, respectively (p=0.002). Median disease-specifc survival was 51 days in GaM-treated animals and 28 days in controls (p=0.004). Complete response was observed in 20% of the animals, with complete resolution of the disease confrmed histo-logically. A partial response was observed in 40% of the animals. Follow-up data is being collected in a second set of animals for verification and updated results will be discussed. CONCLUSION: We present compelling evidence that iron-targeted therapy using the novel iron mimetic GaM is highly effective in treatment-resistant HGG

Safety Outcomes of Mechanical Thrombectomy Versus Combined Thrombectomy and Intravenous Thrombolysis in Tandem Lesions

Background: We aimed to describe the safety and efficacy of mechanical thrombectomy (MT) with or without intravenous thrombolysis (IVT) for patients with tandem lesions and whether using intraprocedural antiplatelet therapy influences MT\u27s safety with IVT treatment. Methods: This is a subanalysis of a pooled, multicenter cohort of patients with acute anterior circulation tandem lesions treated with MT from 16 stroke centers between January 2015 and December 2020. Primary outcomes included symptomatic intracranial hemorrhage (sICH) and parenchymal hematoma type 2. Additional outcomes included hemorrhagic transformation, successful reperfusion (modified Thrombolysis in Cerebral Infarction score 2b-3), complete reperfusion (modified Thrombolysis in Cerebral Infarction score 3), favorable functional outcome (90-day modified Rankin Scale score 0-2), excellent functional outcome (90-day modified Rankin Scale score 0-1), in-hospital mortality, and 90-day mortality. Results: Of 691 patients, 512 were included (218 underwent IVT+MT and 294 MT alone). There was no difference in the risk of sICH (adjusted odds ratio [aOR], 1.22 [95% CI, 0.60-2.51]; P=0.583), parenchymal hematoma type 2 (aOR, 0.99 [95% CI, 0.47-2.08]; P=0.985), and hemorrhagic transformation (aOR, 0.95 [95% CI, 0.62-1.46]; P=0.817) between the IVT+MT and MT alone groups after adjusting for confounders. Administration of IVT was associated with an increased risk of sICH in patients who received intravenous antiplatelet therapy (aOR, 3.04 [95% CI, 0.99-9.37]; P=0.05). The IVT+MT group had higher odds of a 90-day modified Rankin Scale score 0 to 2 (aOR, 1.72 [95% CI, 1.01-2.91]; P=0.04). The odds of successful reperfusion, complete reperfusion, 90-day modified Rankin Scale score 0 to 1, in-hospital mortality, or 90-day mortality did not differ between the IVT+MT versus MT alone groups. Conclusions: Our study showed that the combination of IVT with MT for tandem lesions did not increase the overall risk of sICH, parenchymal hematoma type 2, or overall hemorrhagic transformation independently of the cervical revascularization technique used. However, intraprocedural intravenous antiplatelet therapy during acute stent implantation might be associated with an increased risk of sICH in patients who received IVT before MT. Importantly, IVT+MT treatment was associated with a higher rate of favorable functional outcomes at 90 days

Abstract Number ‐ 243: The Non‐stenosing Carotid Artery Plaque in Embolic Stroke of Undetermined Source: A Retrospective Study

Introduction Atherosclerotic cervical internal carotid artery disease is one of the major causes of ischemic stroke and transient ischemic attacks. The risk of stroke from mild to moderate stenoses (i.e., 1 mm depression (19.08% vs 5.26%, p3 mm (19.08% vs 7.24%, p = 0.001), and plaque length >1cm (13.16% vs 5.92%, p = 0.0218).Also, there was a significant difference in stenosis of ipsilateral to stroke when compared contralaterally, especially for stenoses of 10–30% and 31–49% (17.76% vs 10.53% and 5.26% vs 2.63%, respectively. p = 0.0327). There was also a significant difference in plaque component; both components (soft and calcified) and only soft plaque (42.76% vs 23.68% and 17.76% vs 9.21%, respectively. p< .0001) were more prevalent ipsilaterally. In total, 17patients were found to have a recurrent stroke event, 8 patients had an ipsilateral stroke to the index event, 7 had a bilateral and 2 had a contralateral event. Conclusions ESUS is more commonly found ipsilateral to high‐risk plaque features. Qualitative assessment of plaque features using CTA could be easily implemented in clinical practice. The small number of our sample is definitely a limitation. Further large and multicenter studies aiming to form precise prediction models and scoring systems are needed to help guide treatment with carotid artery stenting or carotid endarterectomy versus maximizing medical therapy

Non-stenosing carotid artery plaques in embolic stroke of undetermined source: a retrospective analysis

BACKGROUND: We aim to identify the association between high-risk carotid plaques and their laterality to stroke in ESUS patient population. We also discuss recurrent stroke events and their laterality to the index stroke. METHODS: This was a retrospective study. We reviewed data for patients with ESUS between June 20, 2016, and June 20, 2021. Using computed tomography angiography, we analyzed plaque features that are associated with ESUS, and then, we identified the recurrent stroke events and characterized lateralization to the index stroke. RESULTS: Out of 1779 patients with cryptogenic ischemic stroke, we included 152 patients who met the criteria for ESUS. High-risk plaque features were found more often ipsilateral to the stroke side when compared contralaterally: plaque ulceration (19.08% vs 5.26%, p \u3c .0001), plaque thickness \u3e 3 mm (19.08% vs 7.24%, p = 0.001), and plaque length \u3e 1 cm (13.16% vs 5.92%, p = 0.0218). There was also a significant difference in plaque component in which both components (soft and calcified) and only soft plaques were more prevalent ipsilaterally (42.76% vs 23.68% and 17.76% vs 9.21%, respectively, p \u3c .0001). Of the 152 patients, 17 patients were found to have a recurrent stroke event, and 47% (n = 8) had an ipsilateral stroke to the index event. Moreover, stroke was bilateral in 41% of the patients (n = 7), and contralateral in 12% (n = 2). CONCLUSION: High-risk plaque features studied here were more prevalent ipsilaterally to the stroke side in ESUS than contralaterally. Multicenter studies are needed to form precise prediction models and scoring systems to help guide treatment, i.e., choice of medical therapy and/or revascularization

Safety of Intravenous Cangrelor Versus Dual Oral Antiplatelet Loading Therapy in Endovascular Treatment of Tandem Lesions: An Observational Cohort Study

Background Procedural intravenous cangrelor has been proposed as an effective platelet inhibition strategy for stenting in acute ischemic stroke. We aimed to compare the safety profile of low‐dose intravenous cangrelor versus dual oral antiplatelet therapy (DAPT) loading in patients with acute cervical tandem lesions. Methods We retrospectively identified cases from an international multicenter cohort who underwent intraprocedural administration of intravenous cangrelor (15 μg/kg followed by an infusion of 2 μg/kg per min) or DAPT loading during acute tandem lesions intervention. Safety outcomes included rates of symptomatic intracranial hemorrhage, parenchymal hematoma type 2, petechial hemorrhage, and in‐stent thrombosis. Inverse probability of treatment weighting matching was used to reduce confounding. Results From 691 patients, we included 195 patients, 30 of whom received intravenous cangrelor and 165 DAPT. The DAPT regimens were aspirin+clopidogrel (93.3%) or aspirin+ticagrelor (6.6%). After inverse probability of treatment weighting, the patients treated with cangrelor were not at greater odds of symptomatic intracranial hemorrhage (odds ratio [OR], 1.30 [95% CI, 0.09–17.3]; P=0.837), symptomatic intracranial hemorrhage–parenchymal hematoma type 2 (OR, 0.54 [95% CI, 0.05–4.98]; P=0.589), or petechial hemorrhage (OR, 1.11 [95% CI, 0.38–3.28]; P=0.836). Similarly, the rate of in‐stent thrombosis was not significantly different between the 2 groups (1.8% versus 0%; P=0.911). Conclusion Cangrelor at the half dose of the myocardial infarction protocol showed a similar safety profile compared with the commonly used DAPT loading protocols in patients with acute tandem lesions. Further studies with larger samples are warranted to elucidate the safety of antiplatelet therapy in tandem lesions

Safety Outcomes of Mechanical Thrombectomy Versus Combined Thrombectomy and Intravenous Thrombolysis in Tandem Lesions

BACKGROUNDWe aimed to describe the safety and efficacy of mechanical thrombectomy (MT) with or without intravenous thrombolysis (IVT) for patients with tandem lesions and whether using intraprocedural antiplatelet therapy influences MT's safety with IVT treatment. METHODSThis is a subanalysis of a pooled, multicenter cohort of patients with acute anterior circulation tandem lesions treated with MT from 16 stroke centers between January 2015 and December 2020. Primary outcomes included symptomatic intracranial hemorrhage (sICH) and parenchymal hematoma type 2. Additional outcomes included hemorrhagic transformation, successful reperfusion (modified Thrombolysis in Cerebral Infarction score 2b-3), complete reperfusion (modified Thrombolysis in Cerebral Infarction score 3), favorable functional outcome (90-day modified Rankin Scale score 0-2), excellent functional outcome (90-day modified Rankin Scale score 0-1), in-hospital mortality, and 90-day mortality. RESULTSOf 691 patients, 512 were included (218 underwent IVT+MT and 294 MT alone). There was no difference in the risk of sICH (adjusted odds ratio [aOR], 1.22 [95% CI, 0.60-2.51]; P=0.583), parenchymal hematoma type 2 (aOR, 0.99 [95% CI, 0.47-2.08]; P=0.985), and hemorrhagic transformation (aOR, 0.95 [95% CI, 0.62-1.46]; P=0.817) between the IVT+MT and MT alone groups after adjusting for confounders. Administration of IVT was associated with an increased risk of sICH in patients who received intravenous antiplatelet therapy (aOR, 3.04 [95% CI, 0.99-9.37]; P=0.05). The IVT+MT group had higher odds of a 90-day modified Rankin Scale score 0 to 2 (aOR, 1.72 [95% CI, 1.01-2.91]; P=0.04). The odds of successful reperfusion, complete reperfusion, 90-day modified Rankin Scale score 0 to 1, in-hospital mortality, or 90-day mortality did not differ between the IVT+MT versus MT alone groups. CONCLUSIONSOur study showed that the combination of IVT with MT for tandem lesions did not increase the overall risk of sICH, parenchymal hematoma type 2, or overall hemorrhagic transformation independently of the cervical revascularization technique used. However, intraprocedural intravenous antiplatelet therapy during acute stent implantation might be associated with an increased risk of sICH in patients who received IVT before MT. Importantly, IVT+MT treatment was associated with a higher rate of favorable functional outcomes at 90 days