Case Report: Repeated Use of Tetrahydrocannabinol Associated with Severe Cerebral Vasoconstriction

Reversible Cerebral Vasoconstriction Syndrome (RCVS) is a rare neurological syndrome. The classic presentation consists of recurrent, severe, ”thunderclap” headaches with neuroimaging findings consistent with segmental vasoconstriction of cerebral arteries. Sympathomimetics including cannabinoids have been found to be triggers in many cases of RCVS. Complications include subarachnoid hemorrhage, intracerebral hemorrhage, cerebral edema and ischemic infarction. This case highlights the potential devastating and irreversible effects of RCVS precipitated by exposure to a sympathomimetic agent. The case emphasizes the importance of patient counseling regarding abstinence from agents that may provoke RCVS

Cerebrovascular events and outcomes in hospitalized patients with COVID-19: The SVIN COVID-19 Multinational Registry

© 2020 World Stroke Organization.[Background]: Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has been associated with a significant risk of thrombotic events in critically ill patients. [Aim]: To summarize the findings of a multinational observational cohort of patients with SARS-CoV-2 and cerebrovascular disease. [Methods]: Retrospective observational cohort of consecutive adults evaluated in the emergency department and/or admitted with coronavirus disease 2019 (COVID-19) across 31 hospitals in four countries (1 February 2020–16 June 2020). The primary outcome was the incidence rate of cerebrovascular events, inclusive of acute ischemic stroke, intracranial hemorrhages (ICH), and cortical vein and/or sinus thrombosis (CVST). [Results]: Of the 14,483 patients with laboratory-confirmed SARS-CoV-2, 172 were diagnosed with an acute cerebrovascular event (1.13% of cohort; 1130/100,000 patients, 95%CI 970–1320/100,000), 68/171 (40.5%) were female and 96/172 (55.8%) were between the ages 60 and 79 years. Of these, 156 had acute ischemic stroke (1.08%; 1080/100,000 95%CI 920–1260/100,000), 28 ICH (0.19%; 190/100,000 95%CI 130–280/100,000), and 3 with CVST (0.02%; 20/100,000, 95%CI 4–60/100,000). The in-hospital mortality rate for SARS-CoV-2-associated stroke was 38.1% and for ICH 58.3%. After adjusting for clustering by site and age, baseline stroke severity, and all predictors of in-hospital mortality found in univariate regression (p < 0.1: male sex, tobacco use, arrival by emergency medical services, lower platelet and lymphocyte counts, and intracranial occlusion), cryptogenic stroke mechanism (aOR 5.01, 95%CI 1.63–15.44, p < 0.01), older age (aOR 1.78, 95%CI 1.07–2.94, p ¼ 0.03), and lower lymphocyte count on admission (aOR 0.58, 95%CI 0.34–0.98, p ¼ 0.04) were the only independent predictors of mortality among patients with stroke and COVID-19. [Conclusions]: COVID-19 is associated with a small but significant risk of clinically relevant cerebrovascular events, particularly ischemic stroke. The mortality rate is high for COVID-19-associated cerebrovascular complications; therefore, aggressive monitoring and early intervention should be pursued to mitigate poor outcomes

Nilotinib-Associated Atherosclerosis Presenting as Multifocal Intracranial Stenosis and Acute Stroke

•Nilotinib, a treatment of CML, has been associated with cardiovascular events with preexisting risk factors and progressive intracranial atherosclerotic disease (ICAD).•We present a case of a patient on nilotinib, without any preexisting vascular risk factors, with acute left middle cerebral artery stroke in the setting of ICAD.•It is important to screen patients for ICAD, even without preexisting cardiovascular risk factors, prior to initiation of nilotinib.•Close monitoring for ICAD is warranted on maintenance therapy of nilotinib for stroke prevention. Nilotinib, a BCR-ABL tyrosine kinase inhibitor (TKI), has been associated with vascular events and accelerated arterial stenosis, presumably of atherosclerotic etiology. Studies of nilotinib-associated atherosclerosis are mainly associated with progressive peripheral artery occlusive disease (PAOD), and only a few cases of coronary artery disease (CAD), and cerebrovascular disease (CVD) have been reported. The mechanisms by which nilotinib promotes atherosclerosis are poorly understood but endothelial and perivascular factors, mast cell depletion, and metabolic factors such as promotion of dyslipidemia and impaired glucose metabolism are thought to play a role. We present a case of a patient with chronic myelogenous leukemia (CML) treated with nilotinib who developed intracranial atherosclerosis leading to acute onset of stroke. Our patient had no cardiovascular risk factors prior to treatment with nilotinib and developed accelerated atheromatous cerebrovascular disease with severe left middle cerebral artery (MCA) stenosis. These findings suggest that nilotinib may be associated with the development of intracranial atherosclerotic disease (ICAD) independently of any preexisting vascular risk factors leading to acute stroke. Clinicians should have increased awareness of the association between nilotinib and the development of progressive atheromatous disease and vascular adverse events including PAOD, CAD, and CVD. In certain patients, these events can be severe and life threatening. Thus, screening for vascular risk factors including CVD prior to starting nilotinib and close follow up during treatment is crucial

Real-world experience with implantable loop recorder monitoring to detect subclinical atrial fibrillation in patients with cryptogenic stroke: The value of p wave dispersion in predicting arrhythmia occurrence.

PURPOSE: We hypothesized patients implanted with ILRs for cryptogenic stroke in real life clinical practice will show an AF detection rate comparable to prior clinical studies, and that clinical or imaging features may help to identify those at higher risk of AF detection. METHODS: A retrospective chart review was conducted of all patients who presented with cryptogenic stroke and received an ILR at an academic medical center from 2015 to 2017 with an active inpatient stroke service. The electronic health record and remote monitoring were used to identify occurrence of AF. RESULTS: A total of 178 patients who received ILRs for cryptogenic stroke were included. Overall, after a thorough evaluation for other etiologies of stroke, 35 (19.6%) were found to have AF detected. Mean follow-up was 365 days with a median time to detection of 131 days. Advanced age (p = 0.001), diastolic dysfunction on echo (p = 0.03), as well as ECG findings of premature atrial contractions (PACs) and p wave dispersion (PWD) \u3e 40 ms were found to be predictive of AF detection (p = 0.04, p \u3c 0.001, respectively). On multiple regression analysis, the only independent predictor of AF detection was PWD \u3e 40 ms. CONCLUSION: After a thorough evaluation to exclude other etiologies for stroke, approximately 20% of patients of our cryptogenic stroke population were found to have AF with ILR surveillance. Advanced age, diastolic dysfunction, as well as ECG findings of PACs and increased PWD may help to predict those at higher risk of AF detection, while PWD was the only independent predictor. This has important clinical implications, as better prediction of AF may help identify those at highest risk and might subsequently aid in guiding therapy

Abstract Number ‐ 109: Mechanical Thrombectomy Hands‐on Skill Workshop for MT2020+ in the Caribbean

Introduction While mechanical thrombectomy (MT) is proven to be lifesaving and disability‐sparing, there remains disparities in access in low‐ to middle‐income countries (LTMICs), including the Caribbean. We hypothesized that team‐oriented MT workshops would improve MT skills and change practice patterns for MT services in this region. Methods We designed a 22‐hour MT workshop which was conducted as two identical events: in English (Jamaica, January 2022), and in Spanish (Dominican Republic, May 2022). The workshops included neurointerventional teams (practicing neurointerventionalists, neuroIR nurses and technicians), focused on patient selection, acutetreatment and post‐MT care of patients with stroke due to large vessel occlusion. MT skills, procedure duration and potential harmful techniques were recorded before and after by independent evaluators utilizing flow models under fluoroscopy. Overall course evaluation was performed. Press conferences were included to raise stroke awareness and emphasize the importance of early stroke presentation. Results Twenty‐two physicians and their teams from eight countries across the Caribbean completed the didactic and hands‐on training. Eighteen groups completed both pre‐ and post‐MT hands‐on testing and were included in the final analysis. Pre‐ and post‐course hands‐on assessment showed that the course effectively reduced the total time to complete a simulated MT procedure from 36.5 to 21.1 min (Figure 1; p< 1.0×10‐7). All groups showed an improvement in measures of good MT techniques, which resulted in a 39% improvement in complete reperfusion (8/18 groups achieved a TICI 3 score on pre‐course vs. 15/18 groups on post‐course). There was a significant reduction in total potentially dangerous maneuvers by 82% (p< 0.002), with 12/18 groups performing an average 2 dangerous maneuvers on pre‐course simulation vs. only 4/18 groups performing an average 1 dangerous maneuver after completing the course. Participants also demonstrated increased knowledge of stroke treatment and stroke system of care. Utilizing a basic stroke knowledge questionnaire, we found 28% respondents did not have a baseline passing grade vs 100% passed after the workshop. The average post‐workshop knowledge score was 80%. Universally the workshop was rated as very satisfactory and likely to change practice in 93% of the Dominican Republic participants and 75% among Jamaican participants. Conclusions A team‐based approach to MT training is novel, effective in reducing time to reperfusion and harmful techniques, and improves competencies. Team members independently demonstrated advanced stroke learning post‐training. To our knowledge, this is the first workshop of its kind; it is feasible, practice‐changing and creates a pathway for increasing access to MT in LTMICs

Stroke etiologies in patients with COVID-19 : the SVIN COVID-19 multinational registry

Coronavirus disease 2019 (COVID-19) is associated with a small but clinically significant risk of stroke, the cause of which is frequently cryptogenic. In a large multinational cohort of consecutive COVID-19 patients with stroke, we evaluated clinical predictors of cryptogenic stroke, short-term functional outcomes and in-hospital mortality among patients according to stroke etiology. We explored clinical characteristics and short-term outcomes of consecutively evaluated patients 18 years of age or older with acute ischemic stroke (AIS) and laboratory-confirmed COVID-19 from 31 hospitals in 4 countries (3/1/20-6/16/20). Of the 14.483 laboratory-confirmed patients with COVID-19, 156 (1.1%) were diagnosed with AIS. Sixty-one (39.4%) were female, 84 (67.2%) white, and 88 (61.5%) were between 60 and 79 years of age. The most frequently reported etiology of AIS was cryptogenic (55/129, 42.6%), which was associated with significantly higher white blood cell count, c-reactive protein, and D-dimer levels than non-cryptogenic AIS patients (p</=0.05 for all comparisons). In a multivariable backward stepwise regression model estimating the odds of in-hospital mortality, cryptogenic stroke mechanism was associated with a fivefold greater odds in-hospital mortality than strokes due to any other mechanism (adjusted OR 5.16, 95%CI 1.41-18.87, p = 0.01). In that model, older age (aOR 2.05 per decade, 95%CI 1.35-3.11, p < 0.01) and higher baseline NIHSS (aOR 1.12, 95%CI 1.02-1.21, p = 0.01) were also independently predictive of mortality. Our findings suggest that cryptogenic stroke among COVID-19 patients carries a significant risk of early mortality. The online version contains supplementary material available at 10.1186/s12883-021-02075-