Intraluminal carotid thrombus leading to postpartum stroke: a case study.

BACKGROUND: Intraluminal non-occlusive thrombus (ILT) is a rare cause of ischemic stroke. Although in most cases ILT is associated with arterial wall disorders, it has also been documented in patients with thrombophilic conditions. CASE REPORT: We present a case of carotid ILT in a 38-year-old puerperal woman with pregnancy-induced hypercoagulability. Following in vitro fertilization pregnancy, she experienced acute left-sided weakness 9 days after delivery. CT angiography revealed an intraluminal filling defect in the right carotid bulb, suggestive of a thrombus, along with ipsilateral MCA sub-occlusion. Mechanical thrombectomy was performed, achieving complete vessel recanalization without any endovascular intervention on the carotid ILT. Comprehensive evaluation excluded any underlying carotid vessel wall disease (such as atherosclerosis, inflammatory diseases, arterial dissection, focal dysplasia), inherited or acquired thrombophilia, and the sole prothrombotic risk factor identified was the puerperium. Histological thrombus analysis showed fibrin/platelet-rich material with significant macrophage infiltration (consistent with an intermediate/organized thrombus, suggesting potential embolization from a pre-existing carotid ILT). Anti-thrombotic treatment (acetylsalicylic acid 100 mg and enoxaparin 6000 UI) resulted in complete thrombus resolution at follow-up. CONCLUSION: ILT should be considered a potential case of embolic stroke in pregnancy or puerperium. Vessel imaging is essential for diagnosis. Histological thrombus analysis can provide insights into the pathophysiological mechanisms of stroke.

Safety and efficacy of endovascular thrombectomy for primary and secondary MeVO.

BACKGROUND: Medium-vessel occlusions (MeVO) are emerging as a new target for endovascular treatment (EVT). Primary MeVO occur de novo, while secondary MeVO arise from large vessel occlusion (LVO) through clot migration or fragmentation - spontaneously, following intravenous thrombolysis or EVT. We aimed to evaluate efficacy and safety of EVT in primary and EVT-induced secondary MeVO. METHODS: Retrospective single-center study on consecutive EVT-treated acute ischemic stroke, from 2019-to-2021. We considered: (1) exclusive-LVO, patients with LVO and - in case of residual distal occlusion - no rescue endovascular procedure; (2) primary MeVO: initial A2, A3, M2 non-dominant, M3, P2, P3 occlusions; (3) EVT-induced secondary MeVO, presenting LVO with subsequent (treated) EVT-induced MeVO. We compared (univariable/multivariable logistic regression) EVT efficacy (eTICI≥2b, 3-month modified Rankin Scale [mRS] 0-2) and safety (EVT-complications [vessel dissection, perforation, persistent-SAH], symptomatic ICH) in all MeVO versus exclusive-LVO, primary MeVO versus exclusive-LVO, EVT-induced secondary MeVO versus exclusive-LVO and EVT-induced secondary MeVO versus primary MeVO. RESULTS: We included 335 patients: 221 (66.0 %) exclusive-LVO and 114 (34.0 %) MeVO (55 [48.2 %] primary, 59 [51.8 %] secondary). Compared to exclusive-LVO, primary MeVO had higher rates of EVT complications (aOR 3.77 [95%CI 1.58-9.00],p=0.003), lower rates of eTICI≥2b (aOR 0.32 [95%CI 0.12-0.88],p=0.027) and mRS 0-2 (aOR 0.28 [95%CI 0.13-0.63],p=0.002). EVT-induced secondary MeVO had no major differences in efficacy and safety outcomes compared to exclusive-LVO, but a better mRS 0-2 (aOR 8.00 [95%CI 2.12-30.17],p=0.002) compared to primary MeVO. CONCLUSIONS: Primary and EVT-induced secondary MeVO showed different safety/efficacy EVT-related profiles. Dedicated randomized data are needed to identify the best acute reperfusion strategy in the two categories.

Endovascular Treatment of Cerebral Vein Thrombosis: Safety and Effectiveness in the Thrombectomy Era.

Cerebral venous thrombosis (CVT) is a rare cause of stroke that tends to affect young people. Endovascular treatment (EVT) has not yet shown to be beneficial in CVT and is therefore actually only indicated as rescue therapy in severe and refractory cases for medical treatment. Clinical, neuroimaging, procedural and follow-up data were evaluated in order to define the safety and efficacy of EVT in the management of CVT between January 2016 and December 2022. Safety was assessed on the basis of recording adverse events. Functional outcomes (NIHSS, mRS) and neuroimaging were recorded at onset, at discharge and at a 6-month follow-up. Efficacy was assessed evaluating the recanalization rate at the end of the procedure. Twenty-one patients (17 female, 4 male, range 16-84 years) with CVT underwent EVT. Overall morbidity and mortality were both at 4.7%. Median NIHSS at the onset and at the discharge were, respectively, 10 and 2. Successful recanalization was achieved in 21/23 procedures (91.3%). Imaging follow-up (FUP) showed stable recanalization in all but one patient with successful recanalization. In 18/21 patients, a good clinical independence (mRS 0-2) was recorded at 6 months. Our study adds evidence on the safety and efficacy of endovascular techniques in the treatment of CVT.

Sero-survey on long-term care facility residents reveals increased risk of sub-optimal antibody response to BNT162b2: implications for breakthrough prevention.

BACKGROUND: The impact of coronavirus disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) on residents of long-term care facilities (LTCFs) has been dramatic on global scale as older age and comorbidities pose an increased risk of severe disease and death. METHODS: Aim of this study was to evaluate SARS-CoV-2 Spike-specific IgG (S-IgG) antibody titers in 478 residents and 649 health care workers of a large Italian long-term care facility two months after complete vaccination with BNT162b2. Associations among resident-related factors and predictors of humoral response were investigated. RESULTS: By stratifying levels of humoral responses, we found that 62.1%, 21.6%, 12.1% and 4.2% of residents had high (>1,000 BAU/ml), medium (101-1,000), low (1-100) and null (<1 BAU/mL) S-IgG titers, respectively. Residents with documented previous COVID-19 and those with SARS-CoV-2 nucleocapsid-specific IgG (N-IgG) positive serology showed higher level of serological response, while significant associations were observed for cancer with suboptimal response (p = 0.005) and the administration of corticosteroid for suboptimal response (p = 0.028) and a null one (p = 0.039). According to multivariate logistic regression, predictors of an increased risk of null response were advanced age (Odd ratio, OR: 2.630; Confidence interval, CI: 1.13-6.14; p = 0.025), corticosteroid therapy (OR: 4.964; CI: 1.06-23.52; p = 0.042) and diabetes mellitus (OR:3.415; CI:1.08-10.8; p = 0.037). In contrast, previous diagnosis of COVID-19 was strongly associated with a reduced risk of null response to vaccination (OR:0.126; CI:0.02-0.23; p < 0.001). CONCLUSIONS: SARS-CoV-2 specific antibodies in elderly individuals should be consider when deciding the need of a third dose of vaccine for prevention of reinfections in LTCFs despite the maintenance of barrier measures.

Durability of Humoral Responses after the Second Dose of mRNA BNT162b2 Vaccine in Residents of a Long Term Care Facility.

Residents of long-term care facilities (LTCFs) have been dramatically hit by the COVID-19 pandemic on a global scale as older age and comorbidities pose an increased risk of severe disease and death. The aim of the study was to assess the quantity and durability of specific antibody responses to SARS-CoV-2 after the first cycle (two doses) of BNT162b2 vaccine. To achieve this, SARS-CoV-2 Spike-specific IgG (S-IgG) titers was evaluated in 432 residents of the largest Italian LTCF at months 2 and 6 after vaccination. By stratifying levels of humoral responses as high, medium, low and null, we did not find any difference when comparing the two time points; however, the median levels of antibodies halved overtime. As positive nucleocapsid serology was associated with a reduced risk of a suboptimal response at both time points, we conducted separate analyses accordingly. In subjects with positive serology, the median level of anti-S IgG slightly increased at the second time point, while a significant reduction was observed in patients without previous exposure to the virus. At month 6, diabetes alone was associated with an increased risk of impaired response. Our data provide additional insights into the longitudinal dynamics of the immune response to BNT162b2 vaccination in the elderly, highlighting the need for SARS-CoV-2 antibody monitoring following third-dose administration.

A Rare Diagnosis After the Fall of a 96-Year-Old Woman: Doege-Potter Syndrome.

INTRODUCTION: Doege-Potter Syndrome (DPS) is a rare but life-threatening paraneoplastic syndrome, characterized by Non-Islet Cell Tumor-Induced Hypoglycemia (NICTH) secondary to a Solitary Fibrous Tumor (SFT), which secretes an incompletely processed form of Insulin-like Growth Factor 2 (IGF-2). RESULTS: A 96-year-old woman was admitted with head trauma due to an accidental fall. During her hospital stay she experienced frequent hypoglycemic episodes. Multiple injections of 33% dextrose and continuous infusion with 10% dextrose were required to maintain normal blood glucose levels. Biochemical analyses revealed hypoinsulinemic hypoglycemia, low C-peptide levels, suppressed insulin-like growth factor-1, normal insulin-like growth factor-2, and an elevated IGF-2:IGF-1 ratio, all consistent with IGF-2 secretion by a non-islet cell tumor. A contrast-enhanced chest and abdominal CT scans showed a single large pleural mass in the left lower hemithorax measuring 15x14 cm without secondary lesions. Histological analysis of biopsied specimens suggested a solitary fibrous pleural tumor; accordingly, a diagnosis of Doege-Potter syndrome was considered. Due to extensive tumor burden and the advanced age of the patient, supportive and non-invasive management was chosen. Dexamethasone therapy was started, and while receiving this therapy she was able to discontinue glucose infusion and successfully maintain euglycemia. DISCUSSION: In the elderly, a sudden and unexplained fall can be the expression of severe hypoglycemia, usually as a complication of insulin therapy or of oral hypoglycemic agents administered to patients with diabetes. However, in patients without diabetes, other causes should be investigated, and the hypothesis of neoplastic diseases should be considered. CONCLUSION: In this case report we describe an uncommon cause of paraneoplastic hypoglycemia occurring in the oldest patient with a non-islet cell tumor reported thus far.