Prevalence of bicuspid aortic valve in patients with aneurysmal sub-arachnoid hemorrhage: neurologic features and outcomes

Background Intracranial aneurysm (IA) has been associated with bicuspid aortic valve (BAV) with prevalence of 6–10% which has led some to recommend routine surveillance for IA in BAV patients. Higher incidence of IA in BAV could signal towards systemic arteriopathy beyond the thoracic aorta. With CoA as an independent risk factor for IA formation, it is currently uncertain if the association between IA and BAV reflects the association of BAV and CoA, or the result of BAV-related systemic arterial changes. Purpose Despite this association, 2 small studies suggest no increased risk of the most important patient outcome: aneurysmal sub-arachnoid hemorrhage (aSAH). Our primary aim was identifying the prevalence of BAV in aSAH patients and compare it with that of a control group without aSAH. Secondary aims included neurologic outcomes of aSAH and anatomical characteristics of IA in BAV, and final disposition and outcome. Methods Patients (>18 years age) with an accurate diagnosis of aSAH and at least one echocardiogram in the system between January 2000-December 2019 were identified from a prospectively maintained registry of aSAH admissions. Controls, without a diagnosis of SAH ever, were age- and gender-matched (1:2 cases:controls). BAV prevalence was echocardiographically-confirmed in all patients. Severity of aSAH was categorized using the modified Fisher (mFisher) and the World Federation of Neurological Scale (WFNS). Results A total of 488 aSAH cases and 990 controls were included in the final analysis with confirmed aortic valve status. The prevalence of BAV in aSAH patients was 1.2% (6/488) vs 3.5% (35/990) in controls, p=0.01. None of the aSAH cases were noted to have CoA, whereas 3 (0.3%; p=0.12) control patients had presence of both BAV and CoA. Within aSAH patients, BAV+aSAH were noted to be younger than tricuspid aortic valve (TAV)+aSAH (56±11 vs 68±14; p=0.03). Aneurysm size was smaller in the BAV+aSAH group (5±2 vs 7±4 in TAV+aSAH; p=0.31). The severity of the bleed was lesser in BAV+aSAH than TAV+aSAH (mFisher grade >2 50% vs 74%; p=0.19, WFNS grade >3 17% vs 36%; p=0.43) which is clinically significant. The BAV+aSAH group had higher disposition rate to home (67% vs 39%; p=0.21) with no difference in in-hospital mortality rates (17% vs 18%; p=0.93). BAV had lower odds on univariate and multivariate analyses adjusted for age/sex/body mass index (OR 0.33 [CI 0.14–0.81]; p=0.01, OR 0.23 [CI 0.08–0.65]; p=0.01) of presenting with aSAH. Conclusion Within a large prospective registry with accurate aSAH diagnoses, we found 3-times lower prevalence of echocardiographically-confirmed BAV as compared to non-aSAH controls. We observed 3-times higher prevalence of BAV in controls than among aSAH cases. In addition, size of intracranial aneurysms was clinically smaller in BAV patients, and the severity of SAH was significantly lesser in BAV from a clinical standpoint. Our findings argue against routine surveillance for IA in BAV patients without CoA. FUNDunding Acknowledgement Type of funding sources: None.

Prevalence Of Intra – Axial Versus Extra – Axial Hemorrhage In The Setting Of Head Trauma Using Computed Tomography

Traumatic Brain Injury presents a global health concern, as it has become one of the leading causes of death and disability worldwide. Non-contrast head computed tomography (CT) scans have been used widely as a diagnostic tool in acute head injury because they are cost-effective, widely available, and detect haemorrhages with high sensitivity. We aimed to study the prevalence of intra and extra axial haemorrhages in patients presenting with head injury in and around Kanchipuram district of Tamil Nadu and also to further identify the commoner types of intracranial haemorrhages associated with such injuries. A retrospective observational study was conducted in the Department Of Radiology, Saveetha Medical College and Hospital for a period of 6 months. Image data from CT scans of the brain were obtained for 50 patients presenting with skull trauma and clinical suspicion of intracranial haemorrhage during the time period from January 2020 to May 2020 and were studied. Based on our study, out of the 50 subjects included it was observed that in the setting of traumatic head injury extra axial hemorrhages are more common than intra axial hemorrhages. Among the type of extra axial hemorrhage , extra dural hemorrhage was far more common than subdural and sub arachnoid hemorrhage especially in presence of skull fractures.

Genetics of Adult Onset Stroke Subtypes: A Review of Current Knowldege and Future Prospects

The genetic contribution in stroke onset depends on the stroke subtypes. Understanding the genetic mechanism may influence the future direction in stroke management. There is complex interplay of genetic and environmental factors for any stroke event. Very small proportion of stroke is attributable to mendelian disorders. Stroke may also manifest as part of a syndromic disease in the form of single gene multisystem disorder. But there is no direct contribution of genetic polymorphism in conventional stroke subtypes. Specific genetic loci increase the suspectibility to development of hypertension, diabetes, dyslipideamia or influence the coagulation pathway or chance of atheroma formation and embolism. While chr9p21 locus or PITX2 and ZFHX3 are related to cardioemetabolic, HDAC9, TSPAN2 and 9p21 locus are responsible for the large vessel occlusion. On the otherhand, genome-wide significant locus on chromosome 1q22 the APOE locus are found to have significant association with intracerebral hemorrhage. But the direct pathophysiologic relationship of genetic plymorphirsm may be linked to onset of sub arachnoid hemorrhage. MMP-3, endothelial nitric oxide synthase (eNOS), tumor necrosis factor (TNF)-α, VCAM-1 etc have been found to be responsible for intracranial aneurysm formation, growth and risk of rupture. Journal of National Institute of Neurosciences Bangladesh, January 2021, Vol. 7, No. 1, pp. 75-86

Oesophageal varices, portal hypertensive gastropathy and spontaneous Sub-arachnoid haemorrhage in a case of liver cirrhosis diagnosed on autopsy.

Alcohol remains one of the most abused substances worldwide. Studies over the years have attributed chronic alcoholism as a major risk factor to liver cirrhosis. Patients with liver cirrhosis develop portal hypertension which put them at a higher risk of having esophageal varices and other associated complications. The authors present a case of a chronic alcoholic male individual who developed cirrhosis along with other less reported complications like sub-arachnoid hemorrhage and portal hypertensive gastropathy. The paper also profiles various changes associated with esophageal varices as observed during autopsy examination.

Remembering John C. Loehlin: ‘Our Field Has Lost a Lion’/Twin Research Reviews: Cognitive Skills and Social Mobility, Risk of Arachnoid Hemorrhage, Heritability of Dental Traits, and Twin-to-Twin Transfusion Syndrome/Media Reports: Identical Twins With Different Health Histories, Twins Born 97 Days Apart, Retiring Twin Tennis Players, TikTok Twins and Twin Reality Stars

John C. Loehlin, professor of psychology at the University of Texas, at Austin, passed away on August 9, 2020. John was 94 years of age. He will be remembered for his seminal contributions that have furthered the field of twin research in so many ways. An overview of his career is presented, with fond memories from his son and several colleagues. This tribute is followed by reviews of twin research on cognitive skills and social mobility, risk of subarachnoid hemorrhage, heritability of selected dental traits and twin-to-twin transfusion syndrome. Finally, twin-related topics of human interest include identical twins with different health histories, twins born 97 days apart, retiring twin tennis players, TikTok twins and twin reality stars.

Clinical Case: Complications after Endovascular Treatment of Intracranial Aneurysm in a Patient after Subarachnoid Hemorrhage

Intracranial aneurysm is one of the most common neurovascular complications. During the recent years the accepted treatment of enraptured cranial aneurysm is noninvasive endovascular coiling. This technique is modern but it is not without complications which can be serious and life-threatening. A clinical case of a patient admitted to the ICU of Military Medical Academy - Sofia with sub arachnoid hemorrhage is described. After a positive clinical course, the check-up magnetic resonance showed intracranial aneurism of the right carotid artery. The patient underwent angiographic endovascular treatment. Vasospasm of the middle and right brain artery and thrombosis were detected during the procedure. Attempt of thromboaspiration was made without success. This article reviews published data on broad-spectrum researches concerning complications of endovascular coiling of intracranial aneurysms and the ways to prevent and reduce them.

Abstract WP387: Race and Sex Differences in Long Term Cognitive Impairment Among Delirious Patients With Acute Neurological Injuries: A Population Based Study

Background: Higher incidence of mild cognitive impairment and dementia (MCID) has been reported in patients with acute neurological injuries (ANI) who are exposed to in-hospital delirium. However, race and sex differences for delirium associated MCID have not been described. Methods: We analyzed State Inpatient and Emergency Department Databases for NY, FL and CA (2006 - 2014) for four categories of adult (≥18) ANI patients (ischemic stroke, intracerebral hemorrhage, sub-arachnoid hemorrhage and traumatic brain injury). Delirium and MCID were tagged using validated diagnostic codes. Patients diagnosed with MCID prior to or within 90-day after ANI event were excluded. We performed time-to-event analyses to explore race and sex differences in development of MCID among delirious ANI patients. Interaction of sex and race with age was also examined. Hazard Ratios (HR) and 95% CIs are reported. Results: We identified 911,380 eligible ANI patients of whom 5.4% were documented to have delirium. After excluding patients without follow-up, we analyzed a total of 34,990 ANI patients with initial in-hospital delirium, among whom 11.5% subsequently developed MCID. In the fully adjusted multivariable model, males had a higher risk of developing MCID (HR, 95% CI: 1.09, 1.01 - 1.16). African Americans, Hispanics and patients in other racial groups also had a higher independent risk of developing MCID, as compared to Caucasians. (Figure 1a). The interaction between age and sex was statically significant (p = 0.04), indicating higher risk of incident MCID among males with increasing age as compared to females. This difference was pronounced beyond 65 years. (Figure 1b). Conclusions: Certain demographic groups hospitalized for ANI may be differentially susceptible to the risk of long-term cognitive decline associated with in-hospital delirium. Targeted and personalized strategies for the early identification and management of delirium during hospitalization may be warranted.