Multidisciplinary Approach to Patent Foramen Ovale Closure for Cryptogenic Stroke: Brain-Heart Board Experience.

Background and Objectives: Patent foramen ovale (PFO) is present in approximately 25% of adult population. The prevalence of PFO is high in patients with cryptogenic stroke suggesting paradoxical embolism. PFO closure in carefully selected patients is an effective secondary preventive strategy in these patients. We report predictors of management recommendations by the multidisciplinary Board and their impact on outcomes. Methods: Brain-Heart Board comprises vascular and interventional neurology and cardiology subspecialties (structural, electrophysiology, and cardiac imaging). Adult patients referred to the Board for consideration of PFO closure between October 2017 to March 2021 were included in this retrospective cohort analysis. Demographics, comorbid conditions, risk of paradoxical embolism (RoPE) score, event frequencies (transient ischemic attack [TIA] or stroke, intracranial hemorrhage [ICH], post-PFO closure cardiac arrhythmias), and modified Rankin Scale (mRS) at 1 year were compared between the groups (PFO closure vs medical management). Multivariable logistic regression was used to identify factors associated with management recommendation and chi-square tests to test differences in outcomes for patients according to management. Results: Two hundred seventy patients (229 stroke; 41 TIA) were discussed by the Board for PFO closure. 119 (44.0%) patients were recommended for PFO closure of which 117 (98.3%) had evidence of ischemic infarct on imaging. In univariate analysis, age was similar (50 ± 11.9 vs 52 ± 12.8, p = 0.17), but RoPE score was higher in closure as compared with the medical management group (6 [IQR 5-7] vs 5 [IQR 4-7], p < 0.05). In multivariable analysis, TIA as the index event was an independent predictor of Board recommendation against PFO closure (OR 0.05, 95% CI 0.01-0.19, p < 0.05). Event frequency was low in both cohorts (5.9% vs 4.8%, p > 0.05) and comprised cardiac arrhythmias (6 cases of atrial fibrillation and 1 ICH in closure group; 1 TIA and 1 recurrent stroke in medical management group). Excellent functional outcome (mRS 0-1) was similar in both cohorts (66.3% vs 70.7%, p > 0.05) at 1 year. Discussion: Multidisciplinary Brain-Heart Board provides a clinical practice model of collaborative care to ensure proper patient selection for PFO closure. TIA as the index event is associated with recommendation of medical management by the multidisciplinary Brain-Heart Board.

Neurogenic cardiac outcome in patients after acute ischemic stroke: The brain and heart connection.

BACKGROUND: Neurogenic cardiac impairment can occur after acute ischemic stroke (AIS), but the mapping of the neuroanatomic correlation of stroke-related myocardial injury remains uncertain. This study aims to identify the association between cardiac outcomes and middle cerebral artery (MCA) ischemic stroke, with or without insular cortex involvement, as well as the impact of new-onset atrial fibrillation (AF) after AIS on recurrent stroke. METHODS: Serial measurements of high sensitivity troponin T (TnT), brain natriuretic peptide (BNP), electrocardiography (ECG), echocardiogram, and cardiac monitoring were performed on 415 patients with imaging confirmed MCA stroke, with or without insular involvement. Patients with renal failure, recent cardiovascular events, or congestive heart failure were excluded. RESULTS: One hundred fifteen patients (28%) had left MCA infarcts with insular involvement, 122 (29%) had right MCA infarcts involving insular cortex, and 178 (43%) had no insular involvement. Patients with left MCA stroke with insular involvement tended to exhibit higher BNP and TnI, and transient cardiac dysfunction, which mimicked Takotsubo cardiomyopathy in 10 patients with left ventricular ejection fraction (LVEF) of 20-40%. Incidence of new-onset AF was higher in right MCA stroke involving insula (39%) than left MCA involving insula (4%). Nine out of fifty-three patients with new-onset AF were not on anticoagulant therapy due to various reasons; none of them experienced recurrent AF or stroke during up to a 3-year follow-up period. Statistically significant correlations between BNP or TnT elevation and left insular infarcts, as well as the incidence of AF and right insular infarcts, were revealed using linear regression analysis. CONCLUSIONS: The present study demonstrated that acute left MCA stroke with insular involvement could cause transient cardiac dysfunction and elevated cardiac enzymes without persistent negative outcomes in the setting of health baseline cardiac condition. The incidence of new-onset AF was significantly higher in patients with right MCA stroke involving the insula. There was no increased risk of recurrent ischemic stroke in nine patients with newly developed AF who were not on anticoagulant therapy, which indicated a need for further research on presumed neurogenic AF and its management.

Shorter Intensive Care Unit Stay (12 Hours) Post Thrombolysis Is Safe and Reduces Length of Stay for Minor Stroke Patients.

The current standard of practice for patients with acute ischemic stroke treated with intravenous tissue-type plasminogen activator (tPA) requires critical monitoring for 24-hours post-treatment due to the risk of symptomatic intracranial hemorrhage (sICH). This is a costly and resource intensive practice. In this study, we evaluated the safety and efficacy of this standard 24-hour ICU monitoring period compared with a shorter 12-hour ICU monitoring period for minor stroke patients (NIHSS 0-5) treated with tPA only. Stroke mimics and those who underwent thrombectomy were excluded. The primary outcome was length of hospital stay. Secondary outcome measures included sICH, deep venous thrombosis (DVT), pulmonary embolism (PE), pneumonia, favorable discharge to home or acute rehabilitation, readmission within 30 days, and favorable functional outcome defined as modified Rankin scale (mRS) of 0-2 at 90 days. Of the 122 patients identified, 77 were in the 24-hour protocol and 45 were in 12-hour protocol. There was significant difference in length of hospital stay for the 24-hour ICU protocol (2.8 days) compared with the 12-hour ICU protocol (1.8 days) (P < 0.001). Although not statistically significant, the 12-hour group had favorable rates of sICH, 30-day readmission rates, favorable discharge disposition and favorable functional outcome. Rates of DVT, PE and aspiration pneumonia were identical between the groups. Compared with 24-hour ICU monitoring, 12-hour ICU monitoring after thrombolysis for minor acute ischemic stroke was not associated with any increase in adverse outcomes. A randomized trial is needed to verify these findings.

Jamestown Canyon Virus (JCV) Encephalitis Mimicking Acute Stroke in Michigan: A Case Report and Review of the Literature.

Jamestown canyon virus (JCV) is an arbovirus and is an under-recognized cause of mosquito-borne viral encephalitis. In this report we present a patient who presented with focal neurological deficits. Patient was initially evaluated for stroke. However, leptomeningeal enhancement on MRI and CSF studies were concerning for viral encephalitis. Brain biopsy and CSF sample from surgical site was positive for JCV IgM antibodies. Patients presenting with concern for viral encephalitis in endemic areas should undergo antibody testing for JCV to guide appropriate treatment.

Impact of a Stay-at-Home Order on Stroke Admission, Subtype, and Metrics during the COVID-19 Pandemic.

OBJECTIVE: Our study aims to evaluate the impact of a stay-at-home order on stroke metrics during the 2019-novel coronavirus (COVID-19) pandemic. METHODS: Data on baseline characteristics, stroke subtype, initial National Institutes of Health Stroke Scale (NIHSS) score, the time between last known well (LKW) to emergency department (ED) arrival, tissue plasminogen activator (tPA) administration, the involvement of large vessel occlusion (LVO), and whether mechanical thrombectomy (MT) was pursued in patients with acute stroke were extracted from 24 March to 23 April 2020 (the time period of a stay-at-home order was placed due to the COVID-19 pandemic as the study group) at a tertiary care hospital in West Michigan, USA, compared with data from 24 March to 23 April 2019 (control group). RESULTS: Our study demonstrated a reduction in cases of acute ischemic stroke (AIS), although this did not reach statistical significance. However, there was an increase in hemorrhagic stroke (7.5% controls vs. 19.2% study group). The age of stroke patients was significantly younger during the period of the stay-at-home order compared to the control group. We identified a significant overall delay of ED arrivals from LKW in the study group. Additionally, an increased number of AIS patients with LVO in the study group (34.8%) was found compared to the control group (17.5%). A significantly increased number of patients received MT in the study group. Additionally, 11 patients were COVID-19 PCR-positive in the study group, 10 with AIS and only 1 with hemorrhagic stroke. Patients with COVID-19 had a high incidence of atrial fibrillation and hyperlipidemia. One AIS patient with COVID-19 rapidly developed cytotoxic edema with corresponding elevated inflammatory biomarkers. No statistical significance was noted when stroke subtype, LVO, and MT groups were compared. CONCLUSIONS: There was a trend of decreasing AIS admissions during the COVID-19 pandemic. There was also a significantly increased number of AIS patients with LVO who received MT, especially those with COVID-19. We conclude that cytokine storm resulting from SARS-CoV-2 infection might play a role in AIS patients with COVID-19.

Mechanical Thrombectomy for Acute Stroke: Early versus Late Time Window Outcomes.

BACKGROUND AND PURPOSE: Recent trials have shown benefit of thrombectomy in patients selected by penumbral imaging in the late (>6 hours) window. However, the role penumbral imaging is not clear in the early (0-6 hours) window. We sought to evaluate if time to treatment modifies the effect of endovascular reperfusion in stroke patients with evidence of salvageable tissue on CT perfusion (CTP). METHODS: We retrospectively analyzed consecutive patients who underwent thrombectomy in a single center. Demographics, comorbidities, National Institute of Health Stroke Scale (NIHSS), rtPA administration, ASPECTS, core infarct volume, onset to skin puncture time, recanalization (mTICI IIb/III), final infarct volume were compared between patients with good and poor 90-day outcomes (mRS 0-2 vs. 3-6). Multivariable logistic regression analyses were used to identify independent predictors of a good (mRS 0-2) 90-day outcome. RESULTS: A total of 235 patients were studied, out of which 52.3% were female. Univariate analysis showed that the groups (early vs. late) were balanced for age (P = .23), NIHSS (P = .63), vessel occlusion location (P = .78), initial core infarct volume (P = .15), and recanalization (mTICI IIb/III) rates (P = .22). Favorable outcome (mRS 0-2) at 90 days (P = .30) were similar. There was a significant difference in final infarct volume (P = .04). Shift analysis did not reveal any significant difference in 90-day outcome (P = .14). After adjustment; age (P < .001), NIHSS (P = .01), recanalization (P = .008), and final infarct volume (P < .001) were predictive of favorable outcome. CONCLUSIONS: Penumbral imaging-based selection of patients for thrombectomy is effective regardless of onset time and yields similar functional outcomes in early and late window patients.

The Role of CT Perfusion in Defining the Clinically Relevant Core Infarction to Guide Thrombectomy Selection in Patients with Acute Stroke.

BACKGROUND AND PURPOSE: Infarct core assessment on presentation is important to evaluate salvageable tissue to select patients for thrombectomy. Our study aims to evaluate the correlation between infarct core volume measured by computed tomography (CT) perfusion (CTP) and magnetic resonance diffusion-weighted imaging (MR-DWI) in patients with acute large-vessel occlusion. METHODS: We studied patients who underwent CTP on presentation to the emergency department for stroke symptoms. National Institute of Health Stroke Scale (NIHSS), collateral status, symptomatic vessels, and modified Rankin scale (mRS) at 90 days were collected. Admission infarct core volume was measured on initial relative cerebral blood volume and final infarct core volume on follow-up DWI. The correlation between two measures was assessed using Pearson's correlation coefficient. RESULTS: Seventy-four patients were studied of which 41.9% were female. Median NIHSS was 13 (2-30). Middle cerebral artery occlusion was present in 53 (71.6%) patients and 54 (72.9%) had good collaterals. Good functional outcome of mRS 0-2 was achieved by 60.8% at 90 days. There was a strong correlation between CTP and MR-DWI (r = .94). There was no significant difference between volume (in milliliters) on CTP (54.1 ± 69.8) and volume on DWI (50.3 ± 59.7; P = .18) using the paired t-test. CONCLUSION: CTP provides a good estimation of the core infarct volume. It performs well within the clinically relevant thresholds for patient selection for thrombectomy.