The cardiovascular risk in bullous pemphigoid: Insights from a population-based study.

BACKGROUND: The risk of life-threatening major cardiovascular outcomes among patients with bullous pemphigoid (BP) is inconsistent in the current literature. OBJECTIVE: To evaluate the risk and prognostic outcomes of myocardial infarction (MI), cerebrovascular accident (CVA), peripheral vascular disease (PVD) and pulmonary embolism (PE) in patients with BP. We additionally aimed to explore the influence of different therapeutic approaches on the risk of these outcomes. METHODS: A population-based retrospective cohort study was conducted to compare BP patients (n = 3924) with age-, gender- and ethnicity-matched control subjects (n = 19,280) with regard to incident cases of MI, CVA, PVD and PE. Adjusted hazard ratio (HR) and 95% confidence intervals (CI) were estimated by multivariate Cox regression analysis. Data were retrieved from Clalit Health Services' computerized database. RESULTS: Relative to their matched controls, patients with BP were at an elevated risk of MI (fully-adjusted HR: 1.44; 95% CI: 1.14-1.81; p = 0.002), CVA (fully-adjusted HR: 1.24; 95% CI: 1.06-1.45; p = 0.007), PVD (fully-adjusted HR: 1.60; 95% CI: 1.27-2.03; p = 0.003) and PE (fully-adjusted HR: 1.72; 95% CI: 1.28-2.32; p < 0.008). Patients with BP experienced heightened risk of all-cause mortality in the presence of comorbid MI (fully-adjusted HR: 1.61; 95% CI: 1.44-1.81; p < 0.001), CVA (fully-adjusted HR: 1.70; 95% CI: 1.52-1.89; p < 0.001), PVD (fully-adjusted HR: 1.38; 95% CI: 1.20-1.58; p < 0.001) and PE (fully-adjusted HR: 1.44; 95% CI: 1.10-1.88; p = 0.007). The therapeutic approach utilized to manage BP did not significantly influence the risk of cardiovascular outcomes. CONCLUSIONS: BP is associated with an elevated risk of MI, CVA, PVD, PE and cardiovascular mortality. Primary, secondary and tertiary cardiovascular prevention measures should be implemented among patients with BP.

Cerebrovascular Accident and SARS-CoV-19 (COVID-19): A Systematic Review.

BACKGROUND: While the most common neurologic symptoms reported in patients affected by SARS-CoV-2 are headache, dizziness, myalgia, mental fog, and anosmia, there is a growing basis of published peer-reviewed cases reporting stroke in the setting of SARS-CoV-2 infection. The peer-reviewed literature suggests an increased risk of cerebrovascular accident (CVA) in the setting of COVID-19 infection. METHODS: We searched 3 databases (PubMed, MEDLINE, and CINAHL) with search terms COVID-19, novel coronavirus, stroke, and cerebrovascular accident. Case series and case studies presenting patients positive for both COVID-19 and CVA published from January 1 through September 1, 2020, were included. Data collection and analysis was completed and risk of bias assessed. RESULTS: The search identified 28 studies across 7 counties comprising 73 patients. Amongst patients hospitalized for COVID-19 infection and CVA, the average age was 60; the most common preexisting conditions were hypertension and diabetes mellitus, and those without preexisting conditions were significantly younger with an average age of 47. Amongst hospitalized patients with COVID-19 and CVA, there was a bimodal association with COVID-19 infection severity with majority of patients classified with mild or critical COVID-19 infection. DISCUSSION: The data suggest SARS-CoV-2 is a risk factor for developing stroke, particularly in patients with hypertension and diabetes. Furthermore, the younger average age of stroke in patients with SARS-CoV-2, particularly those patients with zero identifiable preexisting conditions, creates high suspicion that SARS-CoV-2 is an independent risk factor for development of stroke; however, this cannot yet be proven without comparable control population. The data suggest the risk of developing CVA in the setting of COVID-19 infection is not dependent upon severity of illness. Continued studies must be done to understand the epidemiologic factors of COVID-19 infection and stroke and the pathophysiology of the COVID-associated hypercoagulable state.

Mortality and Cerebrovascular Events After Heart Rhythm Disorder Management Procedures.

BACKGROUND: Recognition of rates and causes of hard, patient-centered outcomes of death and cerebrovascular events (CVEs) after heart rhythm disorder management (HRDM) procedures is an essential step for the development of quality improvement programs in electrophysiology laboratories. Our primary aim was to assess and characterize death and CVEs (stroke or transient ischemic attack) after HRDM procedures over a 17-year period. METHODS: We performed a retrospective cohort study of all patients undergoing HRDM procedures between January 2000 and November 2016 at the Mayo Clinic. Patients from all 3 tertiary academic centers (Rochester, Phoenix, and Jacksonville) were included in the study. All in-hospital deaths and CVEs after HRDM procedures were identified and were further characterized as directly or indirectly related to the HRDM procedure. Subgroup analysis of death and CVE rates was performed for ablation, device implantation, electrophysiology study, lead extraction, and defibrillation threshold testing procedures. RESULTS: A total of 48 913 patients (age, 65.7±6.6 years; 64% male) who underwent a total of 62 065 HRDM procedures were included in the study. The overall mortality and CVE rates in the cohort were 0.36% (95% confidence interval [CI], 0.31-0.42) and 0.12% (95% CI, 0.09-0.16), respectively. Patients undergoing lead extraction had the highest overall mortality rate at 1.9% (95% CI, 1.34-2.61) and CVE rate at 0.62% (95% CI, 0.32-1.07). Among patients undergoing HRDM procedures, 48% of deaths directly related to the HDRM procedure were among patients undergoing device implantation procedures. Overall, cardiac tamponade was the most frequent direct cause of death (40%), and infection was the most common indirect cause of death (29%). The overall 30-day mortality rate was 0.76%, with the highest being in lead extraction procedures (3.08%), followed by device implantation procedures (0.94%). CONCLUSIONS: Half of the deaths directly related to an HRDM procedure were among the patients undergoing device implantation procedures, with cardiac tamponade being the most common cause of death. This highlights the importance of the development of protocols for the quick identification and management of cardiac tamponade even in procedures typically believed to be lower risk such as device implantation.

qEEG in the Diagnosis and Prognosis of a Case with Delusional Infestation.

Stroke can have neuropsychological consequences, such as poststroke psychosis. One aspect of poststroke psychosis is delusional infestation (DI), also known as delusional parasitosis. Patients with DI have fixed sensations that they get infested by lice. Some explanations of DI indicate that striatal and fronto-cortical structural and functional abnormalities are related to DI symptomatology. In this case report, we present a patient with DI due to right intracarotid artery occlusion, which is detected radiologically. Before treatment with escitalopram and risperidone, the case had a frontal slowing in quantitative electroencephalography activity, which was normalized after 2 weeks of treatment. At the end of treatment, psychotic symptoms and OCD symptoms evaluated by the Yale-Brown Obsessive Compulsive Scale, the Scale for the Assessment of Positive Symptoms, were remarkably reduced. These results revealed the role of brain imaging studies in the diagnosis and prognosis of DI.

Abdominal aortic aneurysm rupture presenting with focal weakness and altered mental status: a case report.

BACKGROUND: Abdominal aortic aneurysms (AAA) can present asymptomatically and may be found through routine screening or seen incidentally on imaging. Rupture due to weaking of the aortic wall is the main complication of an AAA and leads to approximately 200,000 deaths annually worldwide. Clinically, AAA rupture most frequently presents with abdominal and/or back pain, pulsatile abdominal mass, and hypotension. Here, we present an unusual presentation of embolic cerebrovascular accident associated with an AAA rupture. CASE PRESENTATION: A 58-year-old African American man transported to the emergency department via ambulance presents with altered mental status and unilateral extremity weakness. The initial presentation was concerning for acute cerebrovascular accident, acute kidney injury, severe sepsis, and urinary tract infection. Several hours after the initial presentation, the patient's abdomen began to appear distended and he became hypotensive. An abdominal CT was ordered which showed a large AAA rupture with a retroperitoneal bleed. The patient was transferred to a higher-level medical center for surgical repair. CONCLUSION: Abdominal aortic aneurysm rupture can rarely present due to an acute cerebrovascular accident with altered mental status and focal neurologic deficits.

Acute and Chronic Cardiovascular Manifestations of COVID-19: Role for Endotheliopathy.

SARS-CoV-2, the virus that causes coronavirus disease 19 (COVID-19), is associated with a bewildering array of cardiovascular manifestations, including myocardial infarction and stroke, myocarditis and heart failure, atrial and ventricular arrhythmias, venous thromboembolism, and microvascular disease. Accumulating evidence indicates that a profound disturbance of endothelial homeostasis contributes to these conditions. Furthermore, the pulmonary infiltration and edema, and later pulmonary fibrosis, in patients with COVID-19 is promoted by endothelial alterations including the expression of endothelial adhesion molecules and chemokines, increased intercellular permeability, and endothelial-to-mesenchyme transitions. The cognitive disturbance occurring in this disease may also be due in part to an impairment of the blood-brain barrier. Venous thrombosis and pulmonary thromboembolism are most likely associated with an endothelial defect caused by circulating inflammatory cytokines and/or direct endothelial invasion by the virus. Endothelial-targeted therapies such as statins, nitric oxide donors, and antioxidants may be useful therapeutic adjuncts in COVID-19 by restoring endothelial homeostasis.

Aspirin Versus Clopidogrel Monotherapy for the Secondary Prevention of Recurrent Cerebrovascular Attack Following Previous Ischemic Stroke in Patients with Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis.

INTRODUCTION: Type 2 diabetes mellitus (T2DM) and stroke are two different diseases, but have many aspects in common. Aspirin is recommended as an initial treatment for the secondary prevention of recurrent ischemic stroke in patients with T2DM. However, clopidogrel is an oral antiplatelet drug that might be another choice in case of aspirin intolerance. In this analysis, we aimed to systematically compare aspirin versus clopidogrel monotherapy for the secondary prevention of recurrent cerebrovascular attack following previous ischemic stroke in patients with T2DM. METHODS: Online medical databases including Web of Science, MEDLINE, Cochrane central, EMBASE and http://www.ClinicalTrials.com were searched for published articles that satisfied the inclusion and exclusion criteria of this study. Recurrent stroke, fatal stroke, cerebral hemorrhage, myocardial infarction and mortality were considered the main end points in these patients with T2DM. RevMan 5.3 software was used to statistically analyze the data representing each subgroup. Risk ratios (RRs) with 95% confidence intervals (CIs) were used to represent the results following analysis. RESULTS: A total of 9218 participants with T2DM who were previously affected by ischemic stroke were included in this analysis, whereby 4917 were assigned to aspirin and 4301 to clopidogrel. This current analysis showed that there was no significant difference in recurrent stroke rate (RR: 0.79, 95% CI: 0.61-1.02; P = 0.07) observed with aspirin versus clopidogrel in these patients with T2DM. The risk of fatal stroke (RR: 0.88, 95% CI: 0.39-1.98; P = 0.76), cerebral hemorrhage (RR: 0.65, 95% CI: 0.38-1.11; P = 0.12), myocardial infarction (RR: 0.88, 95% CI: 0.43-1.79; P = 0.71) and mortality (RR: 1.07, 95% CI: 0.90-1.27; P = 0.44) were also similarly manifested. CONCLUSION: Clopidogrel monotherapy was neither inferior nor superior to aspirin monotherapy for the secondary prevention of recurrent cerebrovascular attack following previous ischemic stroke in patients with T2DM. Hence, clopidogrel or aspirin monotherapy is equally safe and effective in these patients with T2DM.

Imprecise eponyms in stroke medicine - A growing need for uniform terminologies/definitions across the globe.

BACKGROUND: Remarkable advancements in the understanding of etiological risk factors and pathophysiology of cerebrovascular diseases have led to the refining of definitions and terminologies in stroke medicine periodically. We aim to analyze the utility and meaning of different eponyms in the stroke medicine literature during the last 20 years. MATERIALS AND METHODS: A systematic search was performed in Google Scholar for the words "stroke," "TIA," "cerebrovascular accident (CVA)," "cerebrovascular insult," "cerebrovascular event," "cerebral ischemia," and "cerebrovascular disease." Each of the words were searched yearwise from 1996 to 2015, and the numbers of articles using these words were collected and analyzed. RESULTS: ": Stroke" has been the most common terminology used in literature, which showed a progressive increase in its usage until 2010, after which its use drastically reduced. "Cerebrovascular events" and "cerebral ischemia" are the second most commonly used terminologies with variable definitions; there was a steep increase in the use of these words until 2012. CONCLUSIONS: The most imprecise term that continues to be used is "CVA". The precisely defined entity like "cerebrovascular disease," which is a group of diseases, continues to be used inappropriately. All the terms are not defined uniformly across the globe, whereas most continue to use the World Health Organisation definition of stroke, defined in the 1970s. It is essential to condemn the use of imprecise terminologies and promote the use of recently defined precise terms "stroke" and "transient ischemic attack (TIA)". Unless the same terms with precise definitions are used in clinical practice or literature, the progress of stroke medicine will continue to be hampered.

Efficacy of HMG-CoA reductase inhibitors in the prevention of cerebrovascular attack in 1016 patients older than 75 years among 4014 type 2 diabetic individuals.

BACKGROUND/OBJECTIVES: HMG-CoA reductase inhibitors (statins) reduce ischemic heart disease (IHD) in middle-aged diabetic individuals, and LDL-cholesterol (LDL-C) is a risk factor. However, their preventive effects on cerebrovascular attack (CVA) have not been identified in elderly, especially in elderly ≥ 75 years (late elderly), who account for approximately 30% of diabetic individuals in Japan. Randomized controlled studies of statins for late elderly are difficult to carry out, because many co-morbidities in elderly disrupt randomized controlled conditions. METHODS: We performed a prospective cohort study (Japan Cholesterol and Diabetes Mellitus Study) with 5.5 years of follow-up since 2004. A total of 4014 type 2 diabetic patients without previous IHD or CVA (n=1936 women; age = 67.4 ± 9.5 years; ≥ 75 years: n = 1016) were enrolled, while 405 patients were registered as sub-cohort patients. We recorded detailed information on medications and laboratory data after every change in medication in patients of sub-cohort and suffered from IHD or CVA. We subdivided statin-users into prevalent, new and non-users. RESULTS: A total of 104 CVAs occurred during 5.5-years. Plasma HDL-C level was inversely correlated with CVA in patients ≥ 65 years. In case-control study, among patients who were not prescribed statins, CVA increased in age-dependent manner. CVA incidence was lower in prevalent and new statin-users than in non-users (hazard ratio [HR]:0.46, 0.523), especially in late elderly (HR: 0.51, 0.21). Statins reduced CVAs mainly due to a direct effect and partially due to the effects of HDL-C and glucose metabolism. No significant differences were observed between statins. CONCLUSION: Statins prevented CVA in middle-aged, elderly and late elderly diabetic patients via a direct effect. This study is the first to demonstrate the usefulness of observational studies for statistically analyzing agents' effects on late elderly.

Electrocardiographic abnormalities in acute cerebrovascular events in patients with/without cardiovascular disease.

OBJECTIVES: Electrocardiographic (ECG) changes are reported frequently after acute strokes. It seems that cardiovascular effects of strokes are modulated by concomitant or pre-existent cardiac diseases, and are also related to the type of cerebrovascular disease and its localization. We aimed to determine the pattern of ECG changes associated with pathophysiologic categories of acute stroke among patients with/without cardiovascular disease and to determine if specific ECG changes are related to the location of the lesion. MATERIALS AND METHODS: The electrocardiographic records of 361 patients with acute stroke were studied to assess the relative frequencies of ECG abnormalities among the pathophysiologic categories of stroke. RESULTS: In the present study, the most common ECG abnormalities associated with stroke were T-wave abnormalities, prolonged QTc interval and arrhythmias, which were respectively found in 39.9%, 32.4%, and 27.1% of the stroke patients and 28.9%, 30.7%, and 16.2 of the patients with no primary cardiac disease. We observed that other ECG changes comprising pathologic Q- wave, ST-segment depression, ST-segment elevation, and prominent U wave may also occur in selected or non-selected stroke patients; thereby simulate an acute myocardial injury. We observed an increased number of patients with abnormal T-wave and posterior fossa bleedings and more rhythm disturbances for ischemic lesions, localized in the anterior fossa. CONCLUSION: Ischemia-like ECG changes and arrhythmias are frequently seen in stroke patients, even in those with no history or signs of primary heart disease, which support a central nervous system origin of these ECG abnormalities. Further study is necessary to better define the brain-heart interaction.

Efecto terapéutico de los exosomas en el ACV isquémico en animales de experimentación / Therapeutic effect of exosomes on ischemic stroke in experimental animals

La posibilidad de que los exosomas funcionen como una nueva forma de comunicación intercelular para establecer y mantener circuitos cerebrales está comenzando a ser explorada. Los exosomas son liberados desde células e interactúan con otras células receptoras para mediar cambios fisiológicos. Todas las células cerebrales liberan exosomas incluyendo las celulas madre neuronales, las neuronas, astrocitos, microglia, oligodendrocitos y las celulas endoteliales. El objetivo de esta revisión es reunir evidencia actualizada sobre las funciones de protección, antiinflamación y regeneración de los exosomas en el ataque cerebrovascular (ACV) isquémico en ratas. Se realizó una búsqueda sistemática de la literatura sensible y específica en base de datos Medline, EMBASE, Web of Science, Scopus, TRIP database, SciELO y LILACS con términos libres y meSH. Los exosomas generados de CSMs pueden ser utilizados para el tratamiento del ACV. Los exosomas de oligodendrocitos también ejercen una variedad de efectos sobre las neuronas receptoras e influencian un amplio espectro de la fisiología neuronal. En conjunto estos resultados sugieren que los exosomas de las CSMs mediados con miR-133b se transfieren a astrocitos y neuronas, las que regulan la expresión génica, beneficiando tanto la remodelación de neuritas, como la recuperación funcional despues de un ACV. Sería importante en el futuro desarrollar métodos para cuantificar y caracterizar los exosomas en el cerebro con isquemia. Esto permitiría correlacionar entre la cantidad de exosomas en el cerebro y la recuperación funcional entregando información sobre sus mecanismos de acción.

The possibility that exosomes function as a new form of inter cellular communication to establish and maintain brain circuits is beginning to be investigated. Exosomes are released from cells and interact with other receptor cells to mediate physiological changes. All brain cells release exosomes including neural stem cells, neurons, astrocytes, microglia, oligodendrocytes and endothelial cells. The aim of this review is to gather current evidence on the protective, anti-inflammatory and regenerative functions of exosomes in ischemic stroke in rats. A systematic search of sensitive and specific literature was carried out in the following database search engines: Medline, EMBASE, Web of Science, Scopus, TRIP database, SciELO and LILACS with free and MeSH terms data. MSC generated exosomes can be used in the treatment of stroke. Oligodendrocyte exosomes also exert a variety of effects on receptor neurons and influence a wide spectrum of neuronal physiology. Together these results suggest that MSC exosome-mediated transfer of miR-133b to astrocytes and neurons, thus regulating gene expression, benefiting both neurite remodeling, such as functional recovery following a stroke. It would be important in the future to develop methods to quantify and characterize exosomes in brain ischemia. This would allow correlation between the amount of exosomes in the brain and functional recovery providing information relevant to its action mechanisms.

Estudio de frecuencia de los factores de riesgo asociados al desarrollode enfermedad cerebrovascular isquémica no embólica en un hospitalde tercer nivel / Frecuency study of risk factors for cerebrovascular disease development in tertiary hospital in Colombia

Los factores epidemiológicos y las características clínicas de la Enfermedad Cerebrovascular(ECV) varían de acuerdo a factores ambientales, raciales, de género y socioculturales; por tal razón, el conocimientode dichos factores epidemiológicos de riesgo para ECV en nuestra población tiene gran importanciay aporta elementos claves en términos de salud pública.Objetivos. Determinar la frecuencia de los factores de riesgo para el desarrollo de ECV y su tiempo de evolución,así como el número de pacientes que reciben tratamiento para dichos factores de riesgo, la adherenciaal mismo y el seguimiento de recomendaciones de dieta y actividad física.Materiales y métodos. Se realizó un estudio observacional, tipo serie de casos, en pacientes mayores de 18años que consultaron por ECV isquémico en el periodo comprendido entre enero de 2009 hasta septiembrede 2013. Los pacientes se identificaron a través de los códigos CIE-10 contenidos en la base de datos de lainstitución para obtener los registros que incluyeran un diagnóstico principal o relacionado de EnfermedadCerebrovascular Isquémica.Resultados. El promedio de edad fue de 72.7 (SD 12.7) años. Hubo predominio del sexo masculino (50.4%).Conclusiones. La frecuencia de factores de riesgo para ECV parece haber aumentado respecto a publicacionesprevias, posiblemente por modificaciones no saludables en el estilo de vida de la población. El presente estudio brinda información respecto al tratamiento y adherencia farmacológica, ya que realizar un diagnóstico correctode factores de riesgo es muy importante; así mismo, es fundamental instaurar un tratamiento adecuado y, sobre todo, que los pacientes sean adherentes con la terapia para obtener los resultados esperados...

to environmental racial, gender and cultural factors, for this reason, knowledge of the epidemiology of CVDrisk factors in our population is very important and provides key elements in terms of public health.Objective. To determine the frequency of risk factors for the development of CVD and its development time,as well and the number of patients receiving treatment for these risk factors, their adherence to it, in terms offollowing recommendations of diet and physical activity.Materials and Methods. We performed an observational, case series, in patients over 18 years old whoconsulted for ischemic CVD in the period between January 2009 and September 2013. Patients were identifiedby ICD-10 codes in the database for those records or associated with a diagnosis of Ischemic CerebrovascularDisease. Thus, 220 patients met the inclusion criteria. For data collection, a questionnaire was designed to beapplied to each of the records. The information collected was entered in a database in Excel. Descriptive analysiswas performed using STATA statistical software version 12.0. Measures of central tendency and dispersionfor continuous variables and frequencies and proportions for nominal and ordinal variables were estimated...