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Cureus Jun 2024Takotsubo cardiomyopathy (TC) mimics myocardial infarction with symptoms like chest pain, electrocardiogram (EKG) changes, and elevated troponin levels, although it...
Case Report and Literature Review of an Anomalous Course of the Left Main Coronary Artery (LMCA) Arising From the Right Sinus of Valsalva (RSV) Presenting as Takotsubo Cardiomyopathy.
Takotsubo cardiomyopathy (TC) mimics myocardial infarction with symptoms like chest pain, electrocardiogram (EKG) changes, and elevated troponin levels, although it typically features normal coronary arteries upon angiography. While often asymptomatic, coronary artery anomalies (CAAs) can cause intermittent vasospasm and endothelial dysfunction, potentially inducing TC. We report the case of a 74-year-old female with a history of hypertension, hyperlipidemia, and peripheral artery disease, who presented with sudden onset chest pain. Initial EKG and elevated troponin suggested myocardial infarction. However, coronary angiography revealed an anomalous left main coronary artery (LMCA) originating from the right coronary artery (RCA), with no significant stenosis. Subsequent transthoracic echocardiography indicated TC, with the left ventricular ejection fraction improving from 35-40% to 60-65% within days. Cardiac computed tomography angiography (CCTA) revealed that the anomalous LMCA originated from the common trunk at the right sinus of Valsalva (RSV), which further continued as a large, dominant RCA. The LMCA branched into a small to moderate left anterior descending artery (LAD) and a non-dominant left circumflex artery (LCx). The LMCA followed a prepulmonic/anterior course, while the LCx took an interarterial course between the aorta and pulmonary artery. The patient was referred for further surgical evaluation. We conclude that the CAA was an incidental finding and was not related to underlying TC. Although rare, this case suggests a possible correlation between CAAs and a predisposition to stress-induced cardiomyopathy, warranting further investigation.
PubMed: 38919862
DOI: 10.7759/cureus.63028 -
Journal of Anaesthesiology, Clinical... 2024Cervical sympathetic or stellate ganglion blocks (SGBs) have been commonly used in the treatment of painful conditions like complex regional pain syndrome (CRPS).... (Review)
Review
Cervical sympathetic or stellate ganglion blocks (SGBs) have been commonly used in the treatment of painful conditions like complex regional pain syndrome (CRPS). However, there is literature to suggest its utility in managing non-painful conditions as well. The focus of this literature review is to provide an overview of indications for SGB for painful and non-painful conditions. We identified published journal articles in the past 25 years from Embase and PubMed databases with the keywords "cervical sympathetic block, stellate ganglion blocks, cervical sympathetic chain, and cervical sympathetic trunk". A total of 1556 articles were obtained from a literature search among which 311 articles were reviewed. Among painful conditions, there is a lack of evidence in favor of or against the use of SGB for CRPS despite its common use. SGB can provide postoperative analgesia in selective surgeries and can be effective in temporary pain control of refractory angina and the acute phase of herpes zoster infection. Among non-painful conditions, SGB may have beneficial effects on the management of post-traumatic stress disorder (PTSD), refractory ventricular arrhythmias, hot flashes in postmenopausal women, and breast cancer-related lymphedema. Additionally, there have been various case reports illustrating the benefits of SGB in the management of cerebral vasospasm, upper limb erythromelalgia, thalamic and central post-stroke pain, palmar hyperhidrosis, orofacial pain, etc. In our review of literature, we found that SGB can be useful in the management of various non-painful conditions beyond the well-known treatment for CRPS, although further studies are required to prove its efficacy.
PubMed: 38919437
DOI: 10.4103/joacp.joacp_304_22 -
Child's Nervous System : ChNS :... Jun 2024Transcranial doppler based diagnostic criteria for cerebral vasospasm are not well established in the pediatric population because there is no published normative data...
PURPOSE
Transcranial doppler based diagnostic criteria for cerebral vasospasm are not well established in the pediatric population because there is no published normative data to support the diagnosis. Studies have relied on expert consensus, but the definitions have not been validated in children diagnosed with angiographic evidence of vasospasm. Obtaining normative data is a prerequisite to defining pediatric cerebral vasospasm and the Lindegaard Ratio (LR). In this study, we obtained normative data and calculation of the normal LR from healthy children aged 10-16 years.
METHODS
TCD and carotid ultrasonography was used to measure steady state velocities of both the middle cerebral artery (V) and the extracranial internal cerebral artery (V) in healthy children aged 10-16 years. Demographic information, hemodynamic characteristics and the calculated LR (V/V) was determined for each subject using descriptive statistics.
RESULTS
Of the 26 healthy children, 13 were male and 13 were female. V ranged between 53 and 93 cm/sec. LR ranged between 1 and 2.2 for the cohort. V for both males and females were within 2 standard deviations (SD) of the normal mean flow velocity. As the V velocities approached 2 SD above the mean, LR did not exceed 2.2.
CONCLUSION
Our results help define a threshold for LR which can be used to establish radiographic criteria for cerebral vasospasm in children. Our data suggests that using V criteria alone would overestimate cerebral vasospasm and raises question of whether an LR threshold other than 3 is more appropriate for the cut off between hyperemia versus vasospasm in children.
PubMed: 38907117
DOI: 10.1007/s00381-024-06467-9 -
World Neurosurgery Jun 2024Predictors of delayed cerebral infarction (DCI) and early cerebral infraction (ECI) among aneurysmal subarachnoid hemorrhage (aSAH) patients remain unclear. We aimed to... (Review)
Review
BACKGROUND
Predictors of delayed cerebral infarction (DCI) and early cerebral infraction (ECI) among aneurysmal subarachnoid hemorrhage (aSAH) patients remain unclear. We aimed to systematically review and synthesize the literature on predictors of ECI and DCI among aSAH patients.
METHODS
We systematically searched PubMed, EMBASE, Cochrane Library, and Scopus databases comprehensively from inception through January 2024 for observational cohort studies examining predictors of DCI or ECI following aneurysmal SAH. Studies were screened, reviewed, and meta-analyzed, adhering to PRISMA and Cochrane guidelines. The data were pooled as Odds ratios (OR) with 95% confidence intervals (CI) using RevMan 5.4 software. Methodologic quality was assessed with the Newcastle-Ottawa Scale.
RESULTS
Our meta-analysis included 12 moderate to high-quality cohort studies comprising 4527 patients. Regarding DCI predictors, Higher severity scores (O.R.=1.49, 95%CI [1.12,1.97], P=0.005) and high Fisher scores (O.R.=2.23, 95%CI [1.28,3.89], P=0.005) on presentation were significantly associated with an increased risk of DCI. Also, the female sex and the presence of vasospasm were significantly associated with an increased risk of DCI (O.R.=3.04, 95%CI [1.35,6.88], P=0.007). In contrast, preexisting hypertension (p=0.94), aneurysm treatment (p=0.14), and location (p=0.16) did not reliably predict DCI risk. Regarding ECI, the pooled analysis demonstrated no significant associations between sex (P=0.51), pre-existing hypertension (P=0.63), severity (P=0.51), or anterior aneurysm location versus posterior (P=0.86) and the occurrence of ECI.
CONCLUSION
Female sex, admission disease severity, presence of vasospasm and Fisher grading can predict DCI risk post-aSAH. Significant knowledge gaps exist for ECI predictors. Further large standardized cohorts are warranted to guide prognosis and interventions.
PubMed: 38906475
DOI: 10.1016/j.wneu.2024.06.060 -
Neurosurgical Review Jun 2024Delayed cerebral ischemia is a major neurological complication of aneurysmal subarachnoid hemorrhage. Its unpredictable course and potentially unfavorable outcome draw...
Delayed cerebral ischemia is a major neurological complication of aneurysmal subarachnoid hemorrhage. Its unpredictable course and potentially unfavorable outcome draw attention to clinicians to improve the methods for its prediction, prevention, and diagnosis. The computed tomography perfusion (CTP) technique of the brain is one of the promising methods for revealing brain areas endangered by cerebral vasospasm and delayed cerebral ischemia.
Topics: Humans; Brain Ischemia; Subarachnoid Hemorrhage; Tomography, X-Ray Computed; Vasospasm, Intracranial
PubMed: 38904832
DOI: 10.1007/s10143-024-02525-7 -
Frontiers in Neurology 2024Clazosentan, a selective endothelin receptor subtype A antagonist, reduces vasospasm-related morbidity and all-cause mortality following aneurysmal subarachnoid...
INTRODUCTION
Clazosentan, a selective endothelin receptor subtype A antagonist, reduces vasospasm-related morbidity and all-cause mortality following aneurysmal subarachnoid hemorrhage (SAH) in the Japanese population, as demonstrated by a recent randomized phase 3 trial. However, evidence to suggest clazosentan should be prioritized over the current standard of care to prevent cerebral vasospasm is still lacking. Therefore, we investigated the efficacy and safety of clazosentan in comparison with conventional postoperative management in real-world clinical practice.
METHODS
We conducted a single-center, retrospective, observational cohort study using prospectively collected data from consecutive patients with aneurysmal SAH. After clazosentan was approved for use in Japan, the conventional postoperative management protocol, composed of intravenous fasudil chloride and oral cilostazol (control group, April 2021 to March 2022), was changed to the clazosentan protocol (clazosentan group, April 2022 to March 2023). The primary endpoint was the incidence of vasospasm-related symptomatic infarction. The secondary endpoints were favorable functional outcomes (modified Rankin scale score < 3) at discharge, angiographic vasospasm, and the need for rescue therapy for delayed cerebral ischemia.
RESULTS
The analysis included 100 and 81 patients in the control and clazosentan groups, respectively. The incidence of vasospasm-related symptomatic infarction was significantly lower in the clazosentan group than in the control group (6.2% vs. 16%, = 0.032). Multiple logistic analyses demonstrated that the use of clazosentan was independently associated with fewer incidence of vasospasm-related symptomatic infarct (23.8% vs. 47.5%, odds ratio 0.34 [0.12-0.97], = 0.032). Clazosentan was significantly associated with favorable outcomes at discharge (79% vs. 66%, = 0.037). Moreover, both the incidence of angiographic vasospasm (25.9% vs. 44%, = 0.013) and the need for rescue therapy (16.1% vs. 34%, = 0.006) was lower in the clazosentan group. The occurrence of pulmonary edema was significantly higher with clazosentan use (19.8% vs. 5%, = 0.002), which did not result in morbidity.
CONCLUSION
A postoperative management protocol centering on clazosentan was associated with the reduced vasospasm-related symptomatic infarction and improved clinical outcomes compared to the conventional management protocol in Japanese clinical practice. Clazosentan might be a promising treatment option for counteracting cerebral vasospasm after aneurysmal SAH.
PubMed: 38903164
DOI: 10.3389/fneur.2024.1413632 -
EBioMedicine Jun 2024Cerebral vasospasm (CV) is a feared complication which occurs after 20-40% of subarachnoid haemorrhage (SAH). It is standard practice to admit patients with SAH to...
BACKGROUND
Cerebral vasospasm (CV) is a feared complication which occurs after 20-40% of subarachnoid haemorrhage (SAH). It is standard practice to admit patients with SAH to intensive care for an extended period of resource-intensive monitoring. We used machine learning to predict CV requiring verapamil (CVRV) in the largest and only multi-center study to date.
METHODS
Patients with SAH admitted to UCLA from 2013 to 2022 and a validation cohort from VUMC from 2018 to 2023 were included. For each patient, 172 unique intensive care unit (ICU) variables were extracted through the primary endpoint, namely first verapamil administration or no verapamil. At each institution, a light gradient boosting machine (LightGBM) was trained using five-fold cross validation to predict the primary endpoint at various hospitalization timepoints.
FINDINGS
A total of 1750 patients were included from UCLA, 125 receiving verapamil. LightGBM achieved an area under the ROC (AUC) of 0.88 > 1 week in advance and ruled out 8% of non-verapamil patients with zero false negatives. Our models predicted "no CVRV" vs "CVRV within three days" vs "CVRV after three days" with AUCs = 0.88, 0.83, and 0.88, respectively. From VUMC, 1654 patients were included, 75 receiving verapamil. VUMC predictions averaged within 0.01 AUC points of UCLA predictions.
INTERPRETATION
We present an accurate and early predictor of CVRV using machine learning with multi-center validation. This represents a significant step towards optimized clinical management and resource allocation in patients with SAH.
FUNDING
Robert E. Freundlich is supported by National Center for Advancing Translational Sciences federal grant UL1TR002243 and National Heart, Lung, and Blood Institute federal grant K23HL148640; these funders did not play any role in this study. The National Institutes of Health supports Vanderbilt University Medical Center which indirectly supported these research efforts. Neither this study nor any other authors personally received financial support for the research presented in this manuscript. No support from pharmaceutical companies was received.
PubMed: 38901147
DOI: 10.1016/j.ebiom.2024.105206 -
Journal of Cellular and Molecular... Jun 2024Takotsubo syndrome (TTS) is a particular form of acute heart failure that can be challenging to distinguish from acute coronary syndrome at presentation. TTS was... (Review)
Review
Takotsubo syndrome (TTS) is a particular form of acute heart failure that can be challenging to distinguish from acute coronary syndrome at presentation. TTS was previously considered a benign self-limiting condition, but it is now known to be associated with substantial short- and long-term morbidity and mortality. Because of the poor understanding of its underlying pathophysiology, there are few evidence-based interventions to treat TTS. The hypotheses formulated so far can be grouped into endogenous adrenergic surge, psychological stress or preexisting psychiatric illness, coronary vasospasm with microvascular dysfunction, metabolic and energetic alterations, and inflammatory mechanisms. Current evidence demonstrates that the infiltration of immune cells such as macrophages and neutrophils play a pivotal role in TTS. At baseline, resident macrophages were the dominant subset in cardiac macrophages, however, it underwent a shift from resident macrophages to monocyte-derived infiltrating macrophages in TTS. Depletion of macrophages and monocytes in mice strongly protected them from isoprenaline-induced cardiac dysfunction. It is probable that immune cells, especially macrophages, may be new targets for the treatment of TTS.
Topics: Takotsubo Cardiomyopathy; Humans; Inflammation; Animals; Macrophages
PubMed: 38896112
DOI: 10.1111/jcmm.18503 -
Diagnostics (Basel, Switzerland) May 2024Kounis Syndrome (KS) is a clinical entity triggered by allergic or hypersensitivity reactions capable of inducing acute coronary events. Several causes can induce KS,...
Kounis Syndrome (KS) is a clinical entity triggered by allergic or hypersensitivity reactions capable of inducing acute coronary events. Several causes can induce KS, including drugs and insect stings. Here, a rare case of post mortem assessment of fatal KS related to fluorescein retinal angiography has been reported. An 80-year-old man in follow-up for a retinal vein thrombosis underwent a retinal fluoroangiography. Approximately 30 min later, the patient complained of sweating and dizziness, and suddenly lost consciousness due to a cardiac arrest. Despite the immediate cardiopulmonary resuscitation, he died. The autopsy revealed foamy yellowish edema in the respiratory tract and coronary atherosclerosis with eccentric plaques partially obstructing the lumen. The routine histology highlighted lung emphysema and myocyte break-up with foci of contraction band necrosis at the myocardial tissue. Biochemistry showed increased serum tryptase, troponin, and p-BNP. Activated and degranulated (tryptase) mast cells were detected, using immunohistochemistry, in the larynx, lungs, spleen, and heart. Acute myocardial ischemia due to allergic coronary vasospasm related to fluorescein hypersensitivity has been assessed as cause of death. KS-related deaths are considered rare events, and the post mortem assessment of KS quite difficult. The integration of several investigations (gross and microscopic examination, biochemistry, immunohistochemistry) can provide useful findings to support the diagnosis, helping to reduce the unrecognized cases as much as possible.
PubMed: 38893621
DOI: 10.3390/diagnostics14111092 -
Journal of Clinical Medicine May 2024Coronary artery vasospasm plays a crucial role in the prevalence of unstable angina. Despite common misdiagnosis, there is limited evidence on this topic. Here, we...
Coronary artery vasospasm plays a crucial role in the prevalence of unstable angina. Despite common misdiagnosis, there is limited evidence on this topic. Here, we present a rare case of unstable vasospastic angina in a female with severe thyrotoxicosis. : A 62-year-old female patient was admitted to the cardiac intensive care unit due to crushing chest pain at rest. The patient exhibited ischemic changes on the ECG with a normal troponin I level. Recurrent chest pain prompted urgent coronary angiography, revealing generalized vasospasm of all coronary artery branches including the left main coronary artery. Intracoronary nitroglycerin injection partially alleviated the vasospasm; however, there was a persistent stenosis in the left main artery. Subsequent intravascular ultrasound demonstrated an anatomically normal left main artery. Post-procedure, laboratory tests revealed undetectable levels of thyroid-stimulating hormone and thyroid hormones above the detectable level. The patient was initiated on methimazole and discharged symptom-free, expecting a good prognosis under conservative management. : Clinically significant coronary vasospasm triggered by thyrotoxicosis remains a rarity in clinical practice, often posing diagnostic challenges. This case emphasizes the significance of intracoronary nitroglycerin and intravascular ultrasound in discerning the etiology of coronary lesions seen on angiography. We advocate for these techniques to optimize invasive coronary artery diagnostics, enabling the selection of the appropriate treatment strategies and improving long-term prognosis.
PubMed: 38892840
DOI: 10.3390/jcm13113130