Hyperacute Incidental Late Myocardial Enhancement in Ischemic Stroke Using Chest Spectral CT: Relationship with Etiology.

BACKGROUND: Hyperacute cardiac imaging of patients with acute ischemic stroke (AIS), though desirable, is impractical. Using delayed-enhancement, low-dose, non-gated, chest spectral computed tomography scans (DESCT), we explored the prevalence and patterns of incidental myocardial late iodine enhancement (LIE) and embolic sources, and their relationship with stroke etiology. METHODS: Since July 2020, DESCT was performed after cerebrovascular CT angiography (CTA) among patients with suspected AIS undergoing CT using a dual-layer spectral scanner, without additional contrast administration. Images were analyzed using monoenergetic reconstructions and iodine density maps, and the myocardial extracellular volume fraction (ECV, %) was calculated. RESULTS: Eighty patients with AIS were included. DESCT identified a cardiac thrombi in 6 patients (7.5%), and a complex aortic plaque in 4 (5%) cases; reclassifying 5 embolic strokes of uncertain source (28% of ESUS) to cardioembolic (CE, n = 3) and non-CE (n = 2) etiologies. LIE was identified in 38 (48%) patients, most commonly (82%) of ischemic pattern. We did not identify significant relationships between AIS etiology and the presence, pattern, and extent of LIE (p > 0.05); ECV (p = 0.56), severe aortic (p = 0.25) or valvular (p = 0.26) disease, or the extent of coronary calcification (p = 0.39). Patients with evidence of major cardiovascular DESCT findings had higher rates of all-cause death at 90 days (42% vs. 19%, p = 0.037). CONCLUSIONS: In this study, hyperacute cardiac imaging of AIS with DESCT identified a high prevalence of incidental cardiac disease predominantly involving LIE of ischemic etiology and mostly not related to the stroke etiology.

Epicardial and periaortic fat characteristics in ischemic stroke: Relationship with stroke etiology and calcification burden.

PURPOSE: We explored epicardial (EAT) and periaortic (PAT) adipose tissue characteristics in patients with acute ischemic stroke (AIS), and the relationship with stroke etiology, calcification burden, and inflammation. METHOD: We included a retrospective cohort of consecutive patients admitted with AIS between 2015 and 2020 who underwent a chest computed tomography. We calculated volumes and attenuation of EAT and PAT, and coronary artery (CAC), and thoracic aortic (TAC) calcification. Admission's neutrophil/lymphocyte ratio (NLR) was recorded. Stroke severity was assessed using the National Institute of Health Stroke Scale (NIHSS), and patients were discriminated between cardioembolic (CE), non-CE, and embolic strokes of uncertain source (ESUS). RESULTS: A total of 182 patients were included. EAT (non-CE 127.4 ± 47.1 cm3; CE 133.3 ± 56.7 cm3; ESUS 121.6 ± 63.5 cm3, p > 0.05) and PAT (non-CE 37.4 ± 18.6 cm3; CE 40.4 ± 17.2 cm3; ESUS 34.5 ± 14.1 cm3, p > 0.05) volumes were similar between stroke etiologies. Patients with CE stroke had higher PAT attenuation (PAT = non-CE -84.4 ± 7.0 HU; CE -78.1 ± 9.9 HU; ESUS -82.3 ± 9.3 HU, p < 0.001). Using multiple linear regression, albeit weak, we found a significant relationship between NLR and PAT attenuation [Beta 0.24; (95% CI 0.04-0.51), p < 0.05). Despite similar volume, PAT attenuation was higher (p < 0.01) among demised patients. CONCLUSION: In this study, we identified higher periaortic fat attenuation, despite similar fat volume, in patients with CE stroke.

Emerging role of spectral computed tomography in neurocardiology.

The complex and reciprocal relationship between the brain and the heart has gained increasing attention under the concept of neurocardiology. Myocardial injury is common in cerebrovascular disease, and cardiovascular complications are the second leading cause of death after stroke. Cardiac computed tomography (CT) is a fast and reliable non-invasive tool for the assessment of cardioembolic sources. Compared to single energy CT, spectral/dual energy cardiac CT improves tissue characterization and also leads to significant reductions in contrast volume. In this review article, we portray the potential clinical applications of spectral CT in neurocardiology, focusing in the enhanced diagnosis of cardioembolic sources and cardiovascular risk assessment of patients with stroke, including improved detection of thrombus, identification of subtle myocardial disease, and pulmonary complications within the same session.

Cardiovascular thrombotic complications in acute ischemic stroke assessed by chest spectral computed tomography during COVID-19.

During the pandemic context, diagnostic algorithms had to be adapted considering the decimated medical personnel, local technical resources, and the likelihood of contamination. Given the higher probability of thrombotic complications related to COVID-19 and the availability of a dual-layer spectral computed tomography (CT) scanner, we have recently adopted the use of low-dose, non-gated, chest CT scans performed five minutes after contrast administration among patients admitted with acute ischemic stroke (AIS) undergoing cerebrovascular CT angiography. Dual-layer spectral CT comprises a single X-ray source and two-layer detector with different photon-absorption capabilities. In addition to conventional images, the two distinct energy datasets obtained enable multiparametric spectral analysis without need to change the original scanning protocol. The two spectral features that emerge as most useful for patients with AIS are virtual monoenergetic imaging and iodine-based results. Aside from the evaluation of lung parenchyma, this novel strategy enables ruling out cardioembolic sources and simultaneously providing evidence of pulmonary and myocardial injury in a single session and immediately after CT cerebrovascular angiography. Furthermore, it involves a non-invasive, seemingly accurate, unsophisticated, safer (very low radiation dose and no contrast administration), and cheaper tool for ruling out cardioembolic sources compared to transesophageal echocardiogram and cardiac CT. Accordingly, we sought to standardize the technical aspects and overview the usefulness of delayed-phase, low-dose chest spectral CT in patients admitted with AIS.

Early Triage of Cardioembolic Sources Using Chest Spectral Computed Tomography in Acute Ischemic Stroke.

OBJECTIVES: The present study investigated the potential usefulness of delayed-phase, low-dose, non-gated, chest spectral CT scans (DSCT) for the early triage of cardioembolic (CE) sources in patients admitted with acute ischemic stroke (AIS), and for the simultaneous detection of myocardial disease and thrombotic complications. MATERIAL AND METHODS: Since July 2020 and promoted by the COVID-19 pandemic, we implemented the use of DSCT after cerebrovascular CT angiography (CTA) among patients with AIS using a dual-layer spectral CT. We explored the presence of CE sources, as well as late myocardium iodine enhancement (LIE) and pulmonary thromboembolism. Among patients further undergoing transesophageal echocardiogram (TEE) or cardiac CTA, we explored the diagnostic performance. RESULTS: Fifty consecutive patients with AIS who underwent DSCT after cerebrovascular CTA comprised the patient population. The confidence degree for excluding cardiac thrombi was significantly higher than for LIE (4.4±0.8 vs. 3.4±1.3, p<0.0001). DSCT identified a CE source in 4 (8%) and LIE in 24 (48%) patients. The iodine ratio of CE sources was significantly lower compared to the left atrial appendage of patients with no CE sources (0.25±0.1 mg/mL vs. 0.91±0.2 mg/mL, p<0.0001). TEE/cardiac CT, performed in 20 (40%) patients, identified a CE source in 5 (25%) cases, whereas DSCT identified 4 (20%), leading to a sensitivity and specificity of 80% (95% CI 28-99%) and 100% (95% CI 78-100%) respectively (kappa 0.86). CONCLUSIONS: In this pilot study, we identified DSCT as a potential unsophisticated approach for the early triage of CE sources among patients with AIS undergoing CTA upon admission.

Sex-Related Differences after Endovascular Treatment of Acute Ischemic Stroke in the 'Real World'.

BACKGROUND: Gender differences are often reported in the field of ischemic stroke, although most of such discrepancies were observed in randomized trials involving highly selected populations. We therefore explored gender differences regarding 90-day outcomes in large vessel occlusion (LVO) strokes receiving endovascular treatment in a real world setting. METHODS: This prospective registry included anterior and/or posterior circulation LVO strokes admitted between January 2014 and December 2019 who received mechanical thrombectomy up to 24 hours from symptoms onset or last known to be well. We explored sex-related differences in rates of functional independence (modified Rankin Scale, mRS, ≤2) at 90 days. Secondary outcomes included "National Institutes of Health Stroke Scale" (NIHSS) at 24 hours, successful reperfusion defined as modified Thrombolysis in Cerebral Infarction (mTICI) scale 2b/3, death, and symptomatic intracranial hemorrhage (sICH). RESULTS: A total of 288 LVO stroke patients comprised the study population, involving 148 (51.4%) women. Females were older (71.4±15.7 vs. 66.1±14.0 years, p=0.003) and had lower rates of coronary artery disease (15% vs. 24%, p=0.05). The median time from symptoms onset to hospital arrival was 315 min (IQR 139.5-495.0) in females and 255.0 (IQR 117.0-405.0) in males (p=0.052). Rates of mRS ≤2 at 90 days were comparable (females 46% vs. males 49%, p=0.50). Successful reperfusion was achieved in 82% of females and 89% of males (p=0.10). Rates of sICH (females 10% vs. males 13%, p=0.47) and death (females 18% vs. males 21%, p=0.50) at 90 days were similar. NIHSS at 24 hours was the strongest predictor of functional independence at 90 days (area under ROC curve 0.92 (95%CI 0.87; 0.95)]. CONCLUSIONS: Our prospective registry involving a real world setting suggests that females are equally likely to achieve good outcomes after endovascular treatment despite being older and having delayed hospital arrival compared to males. In addition, we found that NIHSS at 24 hours was the strongest predictor of functional independence at 90 days, sICH, and death.

Ataque cerebrovascular isquémico agudo de territorio anterior: Tratamiento endovascular / Acute ischemic stroke in anterior territory: endovascular treatment

La terapia endovascular (TEV) es el tratamiento estándar del ataque cerebrovascular isquémico (ACVi) con oclusión de gran vaso (OGVC). Aún no se conoce si esos resultados pueden generalizarse a la práctica diaria. Se describen los resultados de la TEV en pacientes con ACVi por OGVC dentro de las 24 horas, en un análisis retrospectivo entre enero 2013 y diciembre 2017 que incluyó 139 casos consecutivos con ACVi y OGVC en arteria cerebral media (ACM), hasta 24 horas del inicio de los síntomas, que recibieron TEV en nuestra institución. El resultado primario medido fue la escala de Rankin modificada (mRS) ≤ 2 a 90 días. Se evaluaron también: reperfusión exitosa, según la escala modificada de trombólisis en infarto cerebral (mTICI) 2b/3, hemorragia intracraneal sintomática (HIS) y mortalidad a 90 días. La edad media: 67.5 ± 15.0, siendo el 51.8% mujeres. La mediana basal de National Institute of Health Stroke Scale (NIHSS) fue 14 (IIC 8-18); la mediana del tiempo desde inicio de síntomas hasta punción inguinal: 331 min (IIC 212-503). El 45.3%, 63 pacientes, fueron tratados > 6 horas después del inicio de síntomas. La tasa de mRS ≤ 2 fue 47.5%. Se logró una reperfusión exitosa en el 74.8%. La tasa de mortalidad a 90 días fue del 18.7% y la HIS del 7.9%. Nuestro registro de pacientes de la vida real con ACVi por OGVC tratados con TEV dentro de las 24 horas mostró altas tasas de reperfusión, buenos resultados funcionales y pocas complicaciones, acorde con las recomendaciones internacionales.

Endovascular treatment (EVT) has become the standard of care for acute ischemic stroke (AIS) with proximal large vessel occlusions (LVO). However, it is still unknown whether these results can be generalized to clinical practice. We aimed to perform a retrospective review of patients who received EVT up to 24 hours, and to assess safety and efficacy in everyday clinical practice. We performed a retrospective analysis, from January 2013 to December 2017, on 139 consecutive patients with AIS for anterior circulation LVO strokes up to 24 h from symptoms onset, who received EVT in our institution. The primary outcome measured was a modified Rankin scale (mRS) ≤ 2 at 90 days. Secondary outcomes included successful reperfusion, defined as a modified Thrombolysis in Cerebral Infarction (mTICI) scale 2b/3, mortality rate at 90 days and symptomatic intracranial hemorrhage (sICH). The mean age was 67.5 ± 15.0, with 51.8% female patients. Median baseline National Institute of Health Stroke Scale (NIHSS) was 14 (IQR 8-18); median time from symptom onset to groin puncture was 331 min (IQR 212-503). Sixty-three patients (45.3%) were treated beyond 6 hours after symptoms onset. The rate of mRS ≤ 2 was 47.5%. Successful reperfusion was achieved in 74.8 %. Mortality rate at 90 days was 18.7 % and sICH was 7.9 %. Our registry of real-life patients with AIS due to LVO who received EVT within 24 hours showed high reperfusion rates, and good functional results with few complications, according to international recommendations.

[Acute ischemic stroke in anterior territory: endovascular treatment]. / Ataque cerebrovascular isquémico agudo de territorio anterior. Tratamiento endovascular.

Endovascular treatment (EVT) has become the standard of care for acute ischemic stroke (AIS) with proximal large vessel occlusions (LVO). However, it is still unknown whether these results can be generalized to clinical practice. We aimed to perform a retrospective review of patients who received EVT up to 24 hours, and to assess safety and efficacy in everyday clinical practice. We performed a retrospective analysis, from January 2013 to December 2017, on 139 consecutive patients with AIS for anterior circulation LVO strokes up to 24 h from symptoms onset, who received EVT in our institution. The primary outcome measured was a modified Rankin scale (mRS) = 2 at 90 days. Secondary outcomes included successful reperfusion, defined as a modified Thrombolysis in Cerebral Infarction (mTICI) scale 2b/3, mortality rate at 90 days and symptomatic intracranial hemorrhage (sICH). The mean age was 67.5 ± 15.0, with 51.8% female patients. Median baseline National Institute of Health Stroke Scale (NIHSS) was 14 (IQR 8-18); median time from symptom onset to groin puncture was 331 min (IQR 212-503). Sixty-three patients (45.3%) were treated beyond 6 hours after symptoms onset. The rate of mRS = 2 was 47.5%. Successful reperfusion was achieved in 74.8 %. Mortality rate at 90 days was 18.7 % and sICH was 7.9 %. Our registry of real-life patients with AIS due to LVO who received EVT within 24 hours showed high reperfusion rates, and good functional results with few complications, according to international recommendations.

La terapia endovascular (TEV) es el tratamiento estándar del ataque cerebrovascular isquémico (ACVi) con oclusión de gran vaso (OGVC). Aún no se conoce si esos resultados pueden generalizarse a la práctica diaria. Se describen los resultados de la TEV en pacientes con ACVi por OGVC dentro de las 24 horas, en un análisis retrospectivo entre enero 2013 y diciembre 2017 que incluyó 139 casos consecutivos con ACVi y OGVC en arteria cerebral media (ACM), hasta 24 horas del inicio de los síntomas, que recibieron TEV en nuestra institución. El resultado primario medido fue la escala de Rankin modificada (mRS) = 2 a 90 días. Se evaluaron también: reperfusión exitosa, según la escala modificada de trombólisis en infarto cerebral (mTICI) 2b/3, hemorragia intracraneal sintomática (HIS) y mortalidad a 90 días. La edad media: 67.5 ± 15.0, siendo el 51.8% mujeres. La mediana basal de National Institute of Health Stroke Scale (NIHSS) fue 14 (IIC 8-18); la mediana del tiempo desde inicio de síntomas hasta punción inguinal: 331 min (IIC 212-503). El 45.3%, 63 pacientes, fueron tratados > 6 horas después del inicio de síntomas. La tasa de mRS = 2 fue 47.5%. Se logró una reperfusión exitosa en el 74.8%. La tasa de mortalidad a 90 días fue del 18.7% y la HIS del 7.9%. Nuestro registro de pacientes de la vida real con ACVi por OGVC tratados con TEV dentro de las 24 horas mostró altas tasas de reperfusión, buenos resultados funcionales y pocas complicaciones, acorde con las recomendaciones internacionales.

Left and right atrial function after percutaneous mitral valvuloplasty in mitral stenosis and sinus rhythm.

BACKGROUND AND AIM OF THE STUDY: Percutaneous mitral valvuloplasty (PMV) is an effective method for treating patients with severe mitral stenosis. The study aim was to compare left and right atrial appendage functions before and after PMV. METHODS: Twenty-five patients (23 women, two men; mean age 38 +/- 9 years; range: 21-57 years) with severe mitral stenosis and sinus rhythm who underwent PMV were included in the study. Transesophageal echocardiography (TEE) was performed before and at six months after PMV, to evaluate the intensity of spontaneous echo contrast (SEC), left atrial appendage (LAA) dimensions and function, and right atrial appendage (RAA) function. RESULTS: After PMV, the SEC (at TEE) was decreased in all patients, while increases were observed in the contraction and relaxation velocity flows of the LAA (pre-PMV 18 +/- 5 cm/s; post-PMV 24 +/- 9 cm/s; p < 0.001 and pre-PMV 25.5 +/- 10.2 cm/s; post-PMV 32.9 +/- 12.6 cm/s; p < 0.006, respectively). The tissue myocardial velocities were also increased in the LAA (pre-PMV 6.92 +/- 3.77 cm/s; post-PMV 11.16 +/- 6.61 cm/s; p < 0.002) and RAA (pre-PMV 16.2 +/- 3.7 cm/s; post-PMV 19.1 +/- 4.1 cm/s; p < 0.001). CONCLUSION: In patients with mitral stenosis and sinus rhythm, improvements were noted in the left atrial, LAA and RAA systolic functions after PMV. This suggests that the relief of mitral stenosis may not only confer hemodynamic benefits to improve symptoms but also have a favorable influence on future thromboembolic complications. Thus, an early intervention might benefit patients with sinus rhythm by preventing the development of atrial fibrillation and systemic and pulmonary embolism.