Cerebral blood flow and cognitive functioning in patients with disorders along the heart-brain axis: Cerebral blood flow and the heart-brain axis.

INTRODUCTION: We examined the role of hemodynamic dysfunction in cognition by relating cerebral blood flow (CBF), measured with arterial spin labeling (ASL), to cognitive functioning, in patients with heart failure (HF), carotid occlusive disease (COD), and patients with cognitive complaints and vascular brain injury on magnetic resonance imaging (MRI; ie, possible vascular cognitive impairment [VCI]). METHODS: We included 439 participants (124 HF; 75 COD; 127 possible VCI; 113 reference participants) from the Dutch multi-center Heart-Brain Study. We used pseudo-continuous ASL to estimate whole-brain and regional partial volume-corrected CBF. Neuropsychological tests covered global cognition and four cognitive domains. RESULTS: CBF values were lowest in COD, followed by VCI and HF, compared to reference participants. This did not explain cognitive impairment, as we did not find an association between CBF and cognitive functioning. DISCUSSION: We found that reduced CBF is not the major explanatory factor underlying cognitive impairment in patients with hemodynamic dysfunction along the heart-brain axis.

Nonfocal Transient Neurological Attacks Are Associated With Cerebral Small Vessel Disease.

Background and Purpose- Nonfocal transient neurological attacks (TNAs), such as unsteadiness, bilateral weakness, or confusion, are associated with an increased risk of stroke and dementia. Cerebral ischemia plays a role in their pathogenesis, but the precise mechanisms are unknown. We hypothesized that cerebral small vessel disease is involved in the pathogenesis of TNAs and assessed the relation between TNAs and manifestations of cerebral small vessel disease on magnetic resonance imaging. Methods- We included participants from the HBC (Heart-Brain Connection) study. In this study, hemodynamic and cardiovascular contributions to cognitive impairment have been studied in patients with heart failure, carotid artery occlusion, or possible vascular cognitive impairment, as well as in a reference group. We excluded participants with a history of stroke or transient ischemic attacks. The occurrence of the following 8 TNAs was assessed with a standardized interview: unconsciousness, confusion, amnesia, unsteadiness, bilateral leg weakness, blurred vision, nonrotatory dizziness, and paresthesias. The occurrence of TNAs was related to the presence of lacunes or white matter hyperintensities (Fazekas score, ≥2; early confluent or confluent lesions) in logistic regression analysis, adjusted for age, sex, and hypertension. Results- Of 304 participants (60% men; mean age, 67±9 years), 63 participants (21%) experienced ≥1 TNAs. Lacunes and early confluent or confluent white matter hyperintensities were more common in participants with TNAs than in participants without TNAs (35% versus 20%; adjusted odds ratio, 2.32 [95% CI, 1.22-4.40] and 48% versus 27%; adjusted odds ratio, 2.65 [95% CI, 1.44-4.90], respectively). Conclusions- In our study, TNAs are associated with the presence of lacunes and early confluent or confluent white matter hyperintensities of presumed vascular origin, which indicates that cerebral small vessel disease might play a role in the pathogenesis of TNAs.

Cerebral Perfusion and the Occurrence of Nonfocal Transient Neurological Attacks.

INTRODUCTION: Nonfocal transient neurological attacks (TNAs) are associated with an increased risk of cardiac events, stroke and dementia. Their etiology is still unknown. Global cerebral hypoperfusion has been suggested to play a role in their etiology, but this has not been investigated. We assessed whether lower total brain perfusion is associated with a higher occurrence of TNAs. METHODS: Between 2015 and 2018, patients with heart failure were included in the Heart Brain Connection study. Patients underwent brain magnetic resonance imaging, including quantitative magnetic resonance angiography (QMRA) to measure cerebral blood flow (CBF). We calculated total brain perfusion of each participant by dividing total CBF by brain volume. Patients were interviewed with a standardized questionnaire on the occurrence of TNAs by physicians who were blinded to QMRA flow status. We assessed the relation between total brain perfusion and the occurrence of TNAs with Poisson regression analysis. RESULTS: Of 136 patients (mean age 70 years, 68% men), 29 (21%) experienced ≥1 TNAs. Nonrotatory dizziness was the most common subtype of TNA. Patients with TNAs were more often female and more often had angina pectoris than patients without TNAs, but total CBF and total brain perfusion were not different between both groups. Total brain perfusion was not associated with the occurrence of TNAs (adjusted risk ratio 1.12, 95% CI 0.88-1.42). CONCLUSION: We found no association between total brain perfusion and the occurrence of TNAs in patients with heart failure.

Nonfocal transient neurological attacks in patients with carotid artery occlusion.

INTRODUCTION: Nonfocal transient neurological attacks (TNAs) are episodes with atypical, nonlocalizing cerebral symptoms. We examined the prevalence of nonfocal TNAs, in patients with and without carotid artery occlusion (CAO). METHODS: We included 67 patients with CAO and 62 patients without CAO. In both groups, patients had a history of transient ischemic attack (TIA) or nondisabling ischemic stroke in the anterior circulation that had occurred >6 months before inclusion. Patients without CAO did not have ipsilateral or contralateral carotid artery stenosis of ≥50%. All patients were interviewed with a standardized questionnaire on the occurrence of nonfocal TNA symptoms during the preceding six months. We calculated risk ratios (RRs) with 95% confidence intervals (CIs) for the occurrence of ≥1 and ≥2 different nonfocal TNAs after adjustments for age, sex, systolic blood pressure and time interval between most recent TIA or ischemic stroke and administration of the questionnaire. RESULTS: Forty-three of all patients (33%) had had one or more nonfocal TNAs in the preceding six months. Nonrotatory dizziness (24%) was reported most often. The prevalence of ≥1 nonfocal TNAs was not significantly different between patients with and without CAO (39% vs. 27%; adjusted RR 1.47, 95% CI 0.83-2.61), but the prevalence of ≥2 or more different nonfocal TNAs was higher in patients with CAO (16% vs. 3%; adjusted RR 4.77, 95% CI 1.20-18.98). In patients with CAO who also had a contralateral carotid or vertebral artery steno-occlusion, nonfocal TNAs occurred more often than in patients without any carotid or vertebral artery steno-occlusion (46% vs. 27%; adjusted RR 2.22, 95% CI 1.08-4.60 for ≥1 and 21% vs. 3%; adjusted RR 8.27, 95% CI 1.83-37.32 for ≥2 nonfocal TNAs). CONCLUSIONS: Patients with CAO more often experienced multiple nonfocal TNAs than patients without CAO.

Nonfocal transient neurological attacks are related to cognitive impairment in patients with heart failure.

INTRODUCTION: Nonfocal transient neurological attacks (TNAs) are associated with an increased risk of future dementia, but it is unclear whether TNAs are also associated with concurrent cognitive impairment. We hypothesized that recent TNAs are related to worse cognitive functioning. We tested our hypothesis in patients with heart failure, as these patients are at risk of cerebral hypoperfusion, which might play a role in the etiology of TNAs. METHODS: We performed neuropsychological testing in all patients with heart failure enrolled in the Heart Brain Connection study. We assessed global cognition, attention-psychomotor speed, executive functioning, memory and language. All patients were interviewed with a standardized questionnaire on the occurrence of TNAs in the preceding 6 months. We studied associations between TNAs and cognitive functioning with linear and logistic regression analyses, adjusted for age, sex and education. We performed additional analyses in patients without previous stroke or TIA and in patients without brain infarction on MRI. RESULTS: Thirty-seven (23%) of 158 patients (mean age 70 years, 67% men) experienced one or more TNAs. Patients with a recent TNA were more likely to be impaired on ≥ 1 cognitive domains than patients without TNAs [41% vs. 18%, adjusted odds ratio 4.6, 95% confidence interval (CI) 1.8-11.8]. Patients with TNAs performed worse than patients without TNAs on global cognition (mean difference in z scores - 0.36, 95% CI - 0.54 to - 0.18), and on the cognitive domains attention-psychomotor speed (mean difference - 0.40, 95% CI - 0.66 to - 0.14), memory (mean difference - 0.57, 95% CI - 0.98 to - 0.15) and language (mean difference - 0.47, 95% CI - 0.79 to - 0.16). These associations were independent of cardiac output and volume of white matter hyperintensities. Subgroup analyses in patients without previous stroke or TIA or brain infarction on MRI (n = 78) yielded comparable results, with the exception of the cognitive domain language, which was no longer different between patients with and without TNAs. CONCLUSION: Among patients with heart failure, TNAs are associated with cognitive impairment, which warrants the need for more clinical awareness of this problem.

Complications corner: Anterior thoracic disc surgery with dural tear/CSF fistula and low-pressure pleural drain led to severe intracranial hypotension.

BACKGROUND: Thoracic disc surgery can lead to a life-threatening complication: intracranial hypotension due to a subarachnoid-pleural fistula. CASE DESCRIPTION: We report a 63-year-old male with paraparesis due to multiple herniated thoracic discs, with compressive myelopathy. The patient required a circumferential procedure including a laminectomy/fusion followed by an anterior thoracic decompression to address both diffuse idiopathic skeletal hyperostosis (DISH) anteriorly and posterior stenosis. The postoperative course was complicated by severe intracranial hypotension attributed to the erroneous placement of a low-pressure drain placed in the pleural cavity instead of a lumbar drain; this resulted in subdural hematoma's necessitating subsequent surgery. CONCLUSION: Severe neurological deterioration occurring after thoracic decompressive surgery may rarely be attributed to intracranial hypotension due to a subarachnoid-pleural fistula. Patients should be treated with external lumbar drainage of cerebrospinal fluid for 3-5 days rather than a low-pressure pleural drain to avoid the onset of intracranial hypotension leading to symptomatic subdural hematomas.

[A man with severe traumatic brain injury]. / Een man met ernstig traumatisch schedelhersenletsel.

We present a 41-year-old man with severe traumatic brain injury. Cranial imaging studies revealed cerebral contusion and a longitudinal fracture of the temporal bone. Several days later brain herniated into the left external auditory canal. Imaging studies showed the known skull fracture with a direct connection between the external acoustic meatus and the intracranial structures.