The Left Atrial Septal Pouch as a Possible Risk Factor for Stroke.

BACKGROUND: The left atrial septal pouch (LASP) is formed by the caudal fusion of the area of overlap of the septum primum and the septum secundum, leaving an opening toward the left atrium. The association between LASP and stroke has not been validated by the previous studies. METHODS: The prevalence of the LASP was determined in 223 ischemic stroke patients and 223 control subjects with other cardiac pathologies, in a monocentric retrospective case-control study design. Stroke subtypes were defined according to the modified TOAST criteria. RESULTS: The mean age was 66 ± 15, 54% males, with a high prevalence of cardiovascular risk factors. The prevalence of the LASP was 81 (18%), irrespective of age or pathology. The number of LASP was similar in the stroke and control groups (18% vs. 19%, P = 0.7), as well as in the cryptogenic stroke subgroup (16%, P = 0.6). LASP was not associated with ischemic stroke on univariate (OR = 1.095; 95% CI = 0.676-1.772; P = 0.7) and multivariate logistic regression analysis (OR = 1.004; 95%CI = 0.574-1.758, P = 0.98). There was no statistical association between LASP and cryptogenic stroke on univariate (OR = 1.26; 95%CI = 0.526-3.016; P = 0.6) or multivariate analysis (OR = 0.705; 95%CI = 0.193-2.577, P = 0.6). The association of LASP to AF, left ventricular dysfunction, and thrombophilia did not lead to a higher incidence of stroke (OR = 0.99; 95%CI = 0.37-2.66; P = 0.99). CONCLUSION: Our study did not show any association between LASP and ischemic stroke. A septal pouch was present in 18% of the population. Other associated risk factors need to be considered to incriminate the septal pouch as the etiology of a stroke.

Coumadin ridge mass assessed on three-dimensional transoesophageal echocardiography.

Transoesophageal echocardiography is often recommended in the evaluation of cryptogenic stroke, especially in those patients with no or few risk factors. We report the case of 66-year-old male with a history of multiple ischaemic strokes, admitted to our stroke unit following the discovery of multiple and diffuse new ischaemic lesions on a cerebral magnetic resonance imaging. Transoesophageal echocardiography led to the discovery of a very small mass attached to the tissue fold between the left superior pulmonary vein and the left atrial appendage (often referred to as"coumadin ridge"). The three-dimensional acquisition allowed detailed characterization of this mass. No other source of emboli was detected.The mass was considered to be most likely a tumour and was probably the cause of the multiple strokes. Due to the already advanced neurological disease and the small dimensions of the mass surgery was considered inappropriate. The patient was initiated on oral anticoagulants. This case highlights the importance of three-dimensional ultrasound in the detection and evaluation of intracardiac masses.

Torsade de pointes in Kearns-Sayre syndrome.

A 47-year-old woman with Kearns-Sayre syndrome (KSS) and an implanted pacemaker for complete heart block was admitted to the intensive care unit following a cardiac arrest due to ventricular tachycardia (torsade de pointes) in the setting of QT prolongation. Complete heart blocks and ventricular tachycardia are implicated as mechanisms of sudden deaths in KSS; such patients may require pacemaker implantation and implantation of an automatic implantable cardioverter-defibrillator.

COVID-19 masquerading as a non-convulsive status epilepticus.

Since the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), more and more atypical presentations of COVID-19 are being reported. Here, we present and discuss non-convulsive status epilepticus (NCSE) as presenting symptom of SARS-CoV-2 infection at the Emergency Department.

Prevalence of Left Atrial Septal Pouch Among Patients with Embolic Stroke of Undetermined Source Or Stroke of Known Etiology: a Retrospective Study.

Background and objectives: Cryptogenic strokes can be defined by the criteria established for an embolic stroke of undetermined source (ESUS). Some embolic events might be caused by a left atrial septal pouch (LASP), due to the potential of thrombus formation. In this study we aimed to determine if LASP is a risk factor for ESUS when compared to a population of strokes of known origin, the LASP screening rate in our institution and if LASP dimensions influences the risk of ESUS. Methods: We retrospectively analyzed transesophageal echocardiograms (TEEs) in a large cohort of patients that had experienced ischemic strokes. Two authors performed blinded, independent searches for LASPs by reviewing 1152 TEEs from patients that had experienced a stroke or transient ischemic attack. We excluded 26 TEEs, due to incorrect imaging. Next, we reviewed patient medical files. Results: Among the 1126 included patients, 148 had an ESUS (ESUS+ group) and 978 had strokes of known origin (ESUS- group). A LASP was present in 176 patients, including 32 patients (21.6% of LASPs) in the ESUS+ group and 144 patients (14.7% of LASPs) in the ESUS- group. In multivariate analysis, LASP was independently associated with ESUS (P = 0,019). 61.9% of LASPs that we found were not mentioned in reports from the original TEE operators. Conclusion: This study demonstrated that LASPs were more prevalent in patients with ESUS than in patients with strokes of known origin. Our results gave rise to the question of whether anticoagulation would be appropriate for some patients with ESUS. New large-scale, prospective studies should be conducted to address this issue. Additionally, considering the low rate of LASP descriptions, we concluded that the awareness of operators should be raised to improve their success in identifying LASPs.

Thrombolysis in an Acute Ischemic Stroke Patient on Direct Anticoagulant Therapy Outside of the Traditional Time Window: A Case Report.

A stroke is a life-threatening medical condition that could be disabling if left untreated. Intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) can be effective when initiated in an acute stroke, but their benefit is time-dependent and their use may be restricted by contraindications (CIs) such as anticoagulation therapy. The critical therapeutic time window, which was previously limited to 4.5-6 hours, is now extended to 24 hours in selected patients due to the development of advanced neuroimaging techniques. Herein, we discuss the case of a 50-year-old patient on rivaroxaban who developed acute ischemic stroke (AIS) and was treated successfully with intravenous recombinant tissue plasminogen activator thrombolysis more than six hours after the time he was last seen well (LSW). Our case demonstrates the importance of advanced neuroimaging techniques in identifying AIS candidates for IVT and/or MT with late or unknown time windows as well as the importance of case-by-case assessment when challenged by theoretical contraindications for thrombolysis.

Hyponatremia and stroke mimic: a case report.

The differential diagnosis of acute stroke is often a challenge for the emergency care staff. In medical literature, about 30% of patients presenting in an emergency department with suspected stroke at initial assessment are actually stroke mimic. We report here a case of a 61-year-old woman who got admitted at the emergency service for an acute stroke that was actually a symptomatic hyponatremia due to a Schwartz-Bartter syndrome associated with an undiagnosed breast cancer. It is very important to quickly identify and manage patients presenting with a high probability of acute stroke even though many other pathological conditions can present with the same clinical onset. Electrolyte disturbances are one of those stroke mimic conditions that are usually reversible if properly identified and treated on time.

Cognitive impairment in a patient with COVID-19 on hemodialysis: Too dangerous to neglect!

Neurological manifestations of coronavirus disease 2019 (COVID-19) often have tragic repercussions. Although many reports of neurological complications of severe acute respiratory syndrome coronavirus 2 infection exist, none of them are of patients on hemodialysis, who have a fivefold greater risk of stroke than the general population. In this report, we emphasize the importance of being vigilant for mild stroke in high risk populations-such as patients on hemodialysis-with COVID-19, since these conditions have overlapping symptoms.

Associations of apolipoprotein E gene with ischemic stroke and intracranial atherosclerosis.

The apolipoprotein E (APOE) epsilon4 allele is associated with elevated cholesterol and risk of atherosclerosis. However, its role in ischemic stroke (IS) remains controversial. We investigated a possible link between IS or the severity of intracranial atherosclerosis and the APOE promoter polymorphisms -219G/T and +113G/C, involved in regulating APOE transcription. We genotyped subjects from a multicentric Belgian case-control study, including 237 middle-aged patients with IS due to small- or large-vessel atherosclerotic stroke and 326 ethnicity- and gender-matched controls and a Finnish autopsy series of 1004 non-stroke cases, who had received a quantitative score of atherosclerosis in the circle of Willis. The APOE epsilon4+ genotype did not associate with IS, but was related to more severe intracranial atherosclerosis score in men (5.4 vs 4.6, P=0.044). Within the most common APOE epsilon3/epsilon3 genotype group, the risk of IS associated with the G-allele of the tightly linked -219G/T (OR=6.2; 95% CI: 1.6-24.3, P=0.009) and +113G/C (OR=7.1; 95% CI: 1.7-29.9, P=0.007) promoter polymorphisms. There was no difference in the severity of intracranial atherosclerosis between -219G/G genotype carriers and non-carriers. This study suggests a multifaceted role of apoE on the risk of cerebrovascular diseases. The APOE epsilon4+ genotype did not predict the risk of IS but was associated with severity of subclinical intracranial atherosclerosis in men on the autopsy study. In contrast, the promoter variants were significant predictors of IS, suggesting that quantitative rather than qualitative variation of apoE is related to IS.

The left atrial septal pouch as a risk factor for stroke: A systematic review.

The left atrial septal pouch (LASP) is formed by incomplete fusion of the septum primum and septum secundum, leaving a cavity open towards the left atrium, but without interatrial shunting. There is no recommendation concerning strategy in the presence of a LASP, especially in the setting of stroke. The aim of this review was to determine whether the LASP could be incriminated as the aetiology of a stroke. We included all pertinent publications on the subject, and calculated hazard ratios for ischaemic stroke and cryptogenic stroke. There were only five case-control studies concerning the LASP, involving 516 stroke patients and 779 controls. Overall LASP prevalence was 21%, with a slightly higher prevalence in the cryptogenic stroke group (26%), but this difference was not statistically significant (P=0.27). In a random-effects meta-analysis, there was no difference between controls and patients with ischaemic stroke (hazard ratio 1.20, 95% confidence interval 0.96-1.53; P=0.14). Cryptogenic stroke appeared more frequently in patients with LASP (hazard ratio 1.53, 95% confidence interval 1.07-2.24; P=0.02), but this was driven by only one severely underpowered study. The published case reports demonstrated that thrombus formation inside the pouch can occur in the presence of major predisposing factors. The LASP can be a site for thrombus formation, leading to embolic events, but its presence does not correlate with an increased incidence of stroke. Associated factors should be taken into consideration in the setting of stroke. Further studies are necessary to validate a possible relationship with cryptogenic stroke.

Chronic brain hypoperfusion due to multi-vessel extracranial atherosclerotic disease: a potentially reversible cause of cognitive impairment.

A 62-year-old patient presented with persistent cognitive deficits 3 months after a right temporal ischemic stroke due to ipsilateral carotid occlusion. Work-up disclosed hemodynamically significant contralateral carotid artery stenosis and left subclavian steal phenomenon. Brain SPECT imaging revealed bihemispheric chronic brain hypoperfusion that substantially improved on repeat imaging when the subclavian steal was temporarily diminished by inflating a cuff around the left arm. Carotid endarterectomy of the asymptomatic carotid stenosis substantially ameliorated bihemispheric brain perfusion and reversed cognitive impairment. This case highlights that multi-vessel, extracranial atherosclerotic disease may cause chronic diffuse brain hypoperfusion that can be associated with cognitive impairment.

In situ cytokine immune responses in acute disseminated encephalomyelitis: insights into pathophysiologic mechanisms.

Acute disseminated encephalomyelitis (ADEM) is thought to be an autoimmune disorder of the central nervous system in which myelin is targeted. Pathological studies on closely related human diseases (eg, multiple sclerosis) and on animal models for these demyelinating disorders have suggested the involvement of cytokines. Studies on peripheral immunocytes and on cerebrospinal fluid revealed the presence of cytokine-mediated responses in ADEM. We carried out this neuroimmunopathologic exploration and report for the first time the in situ expression of "inflammatory" cytokines in ADEM. Moreover, we note a particular spatial and molecular pattern whereby tumor necrosis factor-alpha and interleukin (IL)-1beta are intensely expressed, whereas IL-6 is absent. Differential expression at different levels of the neuraxis was also noticed. Our findings suggest that these cytokines, reported to be toxic to myelin, are implicated in the molecular cascade, resulting in the neural damage. These observations might provide insights into molecular pathways involved in the immunopathogenesis of ADEM and might open new horizons in neuroimmunomodulation and anticytokine treatment.

Teaching neuroimages: isolated sphenoiditis: an uncommon cause of abducens nerve palsy.

A 35-year-old woman presented with a headache lasting 2 weeks and complained of recent diplopia. Neurologic examination showed limited left eye abduction. Initial brain CT scan was considered normal (figure, A). Brain MRI showed left sphenoiditis (figure, B). The patient was treated with amoxicillin/clavulanic acid and corticosteroids with rapid symptom improvement which deferred endoscopy that could provide a bacteriologic diagnosis.