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Gao W, Yu L, She J, Sun J, Jin S, Fang J, Chen X, Zhu R. Cardio-cerebral infarction: a narrative review of pathophysiology, treatment challenges, and prognostic implications. Front Cardiovasc Med 2025; 12:1507665. [PMID: 40201791 PMCID: PMC11975930 DOI: 10.3389/fcvm.2025.1507665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2024] [Accepted: 03/12/2025] [Indexed: 04/10/2025] Open
Abstract
Cardio-cerebral infarction (CCI) is a rare clinical syndrome characterized by the simultaneous or sequential occurrence of acute myocardial infarction (AMI) and acute ischemic stroke (AIS). Despite its complex pathogenesis and more severe prognosis compared to isolated AMI or AIS, no consensus has been established regarding its definition, classification, epidemiology, treatment protocols, or prognostic management. Current research is largely confined to case reports or small case series, and there are no unified diagnostic or treatment guidelines, nor any expert consensus. Consequently, clinicians often rely on single-disease guidelines for AMI or AIS, or personal experience, when managing CCI cases. This approach complicates treatment decisions and may result in missed opportunities for optimal interventions, thereby adversely affecting long-term patient outcomes. This narrative review aimed to systematically summarize the definition, classification, epidemiological features, pathogenesis and therapeutic strategies, and prognostic aspects of CCI while thoroughly examining the progress and limitations of existing studies to guide future research and clinical practice. By offering a detailed analysis of reperfusion strategies, antiplatelet therapy, and anticoagulation in CCI patients, this review highlights the safety and efficacy differences among current treatments and explores methods for optimizing individualized management to improve clinical outcomes. Furthermore, this article aimed to enhance clinicians' understanding of CCI, provide evidence-based recommendations for patient care, and outline directions for future research. Ultimately, by refining diagnostic and therapeutic strategies, we aimed to reduce CCI-related mortality and improve long-term prognoses for affected patients.
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Affiliation(s)
- Weiwei Gao
- Department of Neurology, Zhongshan Hospital of Xiamen University, School of Medicine, Xiamen University, National Advanced Center for Stroke, Xiamen, China
| | - Lingfeng Yu
- Department of Neurology, Zhongshan Hospital of Xiamen University, School of Medicine, Xiamen University, National Advanced Center for Stroke, Xiamen, China
| | - Jingjing She
- Department of Neurology, Zhongshan Hospital of Xiamen University, School of Medicine, Xiamen University, National Advanced Center for Stroke, Xiamen, China
| | - Junxuan Sun
- Department of Emergency, Zhongshan Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Shouyue Jin
- Department of Neurology, Zhongshan Hospital of Xiamen University, School of Medicine, Xiamen University, National Advanced Center for Stroke, Xiamen, China
| | - Jingjing Fang
- Department of Cardiology, West China Xiamen Hospital of Sichuan University, Xiamen, China
| | - Xingyu Chen
- Department of Neurology, Zhongshan Hospital of Xiamen University, School of Medicine, Xiamen University, National Advanced Center for Stroke, Xiamen, China
| | - Renjing Zhu
- Department of Neurology, Zhongshan Hospital of Xiamen University, School of Medicine, Xiamen University, National Advanced Center for Stroke, Xiamen, China
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2
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Valenza G, Matić Z, Catrambone V. The brain-heart axis: integrative cooperation of neural, mechanical and biochemical pathways. Nat Rev Cardiol 2025:10.1038/s41569-025-01140-3. [PMID: 40033035 DOI: 10.1038/s41569-025-01140-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2025] [Indexed: 03/05/2025]
Abstract
The neural and cardiovascular systems are pivotal in regulating human physiological, cognitive and emotional states, constantly interacting through anatomical and functional connections referred to as the brain-heart axis. When this axis is dysfunctional, neurological conditions can lead to cardiovascular disorders and, conversely, cardiovascular dysfunction can substantially affect brain health. However, the mechanisms and fundamental physiological components of the brain-heart axis remain largely unknown. In this Review, we elucidate these components and identify three primary pathways: neural, mechanical and biochemical. The neural pathway involves the interaction between the autonomic nervous system and the central autonomic network in the brain. The mechanical pathway involves mechanoreceptors, particularly those expressing mechanosensitive Piezo protein channels, which relay crucial information about blood pressure through peripheral and cerebrovascular connections. The biochemical pathway comprises many endogenous compounds that are important mediators of neural and cardiovascular function. This multisystem perspective calls for the development of integrative approaches, leading to new clinical specialties in neurocardiology.
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Affiliation(s)
- Gaetano Valenza
- Neurocardiovascular Intelligence Lab, Department of Information Engineering & Research Center "E. Piaggio", University of Pisa, Pisa, Italy.
| | - Zoran Matić
- Neurocardiovascular Intelligence Lab, Department of Information Engineering & Research Center "E. Piaggio", University of Pisa, Pisa, Italy
| | - Vincenzo Catrambone
- Neurocardiovascular Intelligence Lab, Department of Information Engineering & Research Center "E. Piaggio", University of Pisa, Pisa, Italy
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3
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Herring N, Ajijola OA, Foreman RD, Gourine AV, Green AL, Osborn J, Paterson DJ, Paton JFR, Ripplinger CM, Smith C, Vrabec TL, Wang HJ, Zucker IH, Ardell JL. Neurocardiology: translational advancements and potential. J Physiol 2025; 603:1729-1779. [PMID: 39340173 PMCID: PMC11955874 DOI: 10.1113/jp284740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 09/03/2024] [Indexed: 09/30/2024] Open
Abstract
In our original white paper published in the The Journal of Physiology in 2016, we set out our knowledge of the structural and functional organization of cardiac autonomic control, how it remodels during disease, and approaches to exploit such knowledge for autonomic regulation therapy. The aim of this update is to build on this original blueprint, highlighting the significant progress which has been made in the field since and major challenges and opportunities that exist with regard to translation. Imbalances in autonomic responses, while beneficial in the short term, ultimately contribute to the evolution of cardiac pathology. As our understanding emerges of where and how to target in terms of actuators (including the heart and intracardiac nervous system (ICNS), stellate ganglia, dorsal root ganglia (DRG), vagus nerve, brainstem, and even higher centres), there is also a need to develop sensor technology to respond to appropriate biomarkers (electrophysiological, mechanical, and molecular) such that closed-loop autonomic regulation therapies can evolve. The goal is to work with endogenous control systems, rather than in opposition to them, to improve outcomes.
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Affiliation(s)
- N. Herring
- Department of Physiology, Anatomy and GeneticsUniversity of OxfordOxfordUK
| | - O. A. Ajijola
- UCLA Neurocardiology Research Center of ExcellenceDavid Geffen School of MedicineLos AngelesCAUSA
| | - R. D. Foreman
- Department of Biochemistry and PhysiologyUniversity of Oklahoma Health Sciences CenterOklahoma CityOKUSA
| | - A. V. Gourine
- Centre for Cardiovascular and Metabolic NeuroscienceUniversity College LondonLondonUK
| | - A. L. Green
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
| | - J. Osborn
- Department of SurgeryUniversity of MinnesotaMinneapolisMNUSA
| | - D. J. Paterson
- Department of Physiology, Anatomy and GeneticsUniversity of OxfordOxfordUK
| | - J. F. R. Paton
- Manaaki Manawa – The Centre for Heart Research, Department of Physiology, Faculty of Medical and Health SciencesUniversity of AucklandAucklandNew Zealand
| | - C. M. Ripplinger
- Department of PharmacologyUniversity of California DavisDavisCAUSA
| | - C. Smith
- Department of Physiology and BiophysicsCase Western Reserve UniversityClevelandOHUSA
| | - T. L. Vrabec
- Department of Physical Medicine and Rehabilitation, School of MedicineCase Western Reserve UniversityClevelandOHUSA
| | - H. J. Wang
- Department of AnesthesiologyUniversity of Nebraska Medical CenterOmahaNEUSA
| | - I. H. Zucker
- Department of Cellular and Integrative PhysiologyUniversity of Nebraska Medical CenterOmahaNEUSA
| | - J. L. Ardell
- UCLA Neurocardiology Research Center of ExcellenceDavid Geffen School of MedicineLos AngelesCAUSA
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4
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Macom RV, Brown CM. Gastrointestinal Dysfunction and Dysbiosis in Ischemic Stroke: Opportunities for Therapeutic Intervention. Pharmaceuticals (Basel) 2025; 18:320. [PMID: 40143100 PMCID: PMC11944649 DOI: 10.3390/ph18030320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 02/11/2025] [Accepted: 02/23/2025] [Indexed: 03/28/2025] Open
Abstract
Although strokes originate in the brain, it is now widely appreciated that peripheral organ systems are also impacted by stroke. The gastrointestinal system is one peripheral organ system that is impaired during ischemic stroke. This impairment results in numerous complications, which impede post-stroke recovery. Many of the gastrointestinal mechanisms that contribute to the pathophysiology of ischemic stroke remain poorly understood. This review will highlight the molecular and cellular mechanisms underlying gastrointestinal outcomes in stroke by focusing on the complex interactions that largely occur in the small intestine. The final portion of this review will focus on therapeutic interventions that target the gut as a strategy to prevent or delay functional impairment and cognitive disability in stroke patients.
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Affiliation(s)
- Rhiannon V. Macom
- Department of Microbiology, Immunology and Cell Biology, West Virginia University School of Medicine, Morgantown, WV 26506, USA;
| | - Candice M. Brown
- Department of Microbiology, Immunology and Cell Biology, West Virginia University School of Medicine, Morgantown, WV 26506, USA;
- Department of Neuroscience, Rockefeller Neuroscience Institute, West Virginia University School of Medicine, Morgantown, WV 26506, USA
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5
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Fontes MAP, Dos Santos Machado LR, Viana ACR, Cruz MH, Nogueira ÍS, Oliveira MGL, Neves CB, Godoy ACV, Henderson LA, Macefield VG. The insular cortex, autonomic asymmetry and cardiovascular control: looking at the right side of stroke. Clin Auton Res 2024; 34:549-560. [PMID: 39316247 DOI: 10.1007/s10286-024-01066-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 09/09/2024] [Indexed: 09/25/2024]
Abstract
PURPOSE Evidence from animal and human studies demonstrates that cortical regions play a key role in autonomic modulation with a differential role for some brain regions located in the left and right brain hemispheres. Known as autonomic asymmetry, this phenomenon has been demonstrated by clinical observations, by experimental models, and currently by combined neuroimaging and direct recordings of sympathetic nerve activity. Previous studies report peculiar autonomic-mediated cardiovascular alterations following unilateral damage to the left or right insula, a multifunctional key cortical region involved in emotional processing linked to autonomic cardiovascular control and featuring asymmetric characteristics. METHODS Based on clinical studies reporting specific damage to the insular cortex, this review aims to provide an overview of the prognostic significance of unilateral (left or right hemisphere) post-insular stroke cardiac alterations. In addition, we review experimental data aiming to unravel the central mechanisms involved in post-insular stroke cardiovascular complications. RESULTS AND CONCLUSION Current clinical and experimental data suggest that stroke of the right insula can present a worse cardiovascular prognosis.
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Affiliation(s)
- Marco Antônio Peliky Fontes
- Hypertension Laboratory, Department of Physiology and Biophysics - Institute of Biological Sciences, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, 31270 901, Brazil.
| | - Liliane Ramos Dos Santos Machado
- Hypertension Laboratory, Department of Physiology and Biophysics - Institute of Biological Sciences, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, 31270 901, Brazil
| | - Ana Clara Rocha Viana
- Hypertension Laboratory, Department of Physiology and Biophysics - Institute of Biological Sciences, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, 31270 901, Brazil
| | - Matheus Henrique Cruz
- Hypertension Laboratory, Department of Physiology and Biophysics - Institute of Biological Sciences, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, 31270 901, Brazil
| | - Ícaro Santos Nogueira
- Hypertension Laboratory, Department of Physiology and Biophysics - Institute of Biological Sciences, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, 31270 901, Brazil
| | - Marcela Gondim Lima Oliveira
- Hypertension Laboratory, Department of Physiology and Biophysics - Institute of Biological Sciences, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, 31270 901, Brazil
| | - Christiane Braga Neves
- Hypertension Laboratory, Department of Physiology and Biophysics - Institute of Biological Sciences, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, 31270 901, Brazil
| | - Ana Caroline Ventris Godoy
- Hypertension Laboratory, Department of Physiology and Biophysics - Institute of Biological Sciences, Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, 31270 901, Brazil
| | | | - Vaughan G Macefield
- Department of Neuroscience, Monash University, Melbourne, Australia
- Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, Australia
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Khalil M, Lau HC, Thackeray JT, Mikail N, Gebhard C, Quyyumi AA, Bengel FM, Bremner JD, Vaccarino V, Tawakol A, Osborne MT. Heart-brain axis: Pushing the boundaries of cardiovascular molecular imaging. J Nucl Cardiol 2024; 36:101870. [PMID: 38685398 PMCID: PMC11180568 DOI: 10.1016/j.nuclcard.2024.101870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 04/18/2024] [Accepted: 04/22/2024] [Indexed: 05/02/2024]
Abstract
Despite decades of research, the heart-brain axis continues to challenge investigators seeking to unravel its complex pathobiology. Strong epidemiologic evidence supports a link by which insult or injury to one of the organs increases the risk of pathology in the other. The putative pathways have important differences between sexes and include alterations in autonomic function, metabolism, inflammation, and neurohormonal mechanisms that participate in crosstalk between the heart and brain and contribute to vascular changes, the development of shared risk factors, and oxidative stress. Recently, given its unique ability to characterize biological processes in multiple tissues simultaneously, molecular imaging has yielded important insights into the interplay of these organ systems under conditions of stress and disease. Yet, additional research is needed to probe further into the mechanisms underlying the heart-brain axis and to evaluate the impact of targeted interventions.
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Affiliation(s)
- Maria Khalil
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Boston, MA, USA; Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Hui Chong Lau
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Boston, MA, USA; Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - James T Thackeray
- Department of Nuclear Medicine, Hannover Medical School, Hannover, Germany
| | - Nidaa Mikail
- Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland; Center for Molecular Cardiology, University Hospital Zurich, Schlieren, Switzerland
| | - Catherine Gebhard
- Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland; Center for Molecular Cardiology, University Hospital Zurich, Schlieren, Switzerland; Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Arshed A Quyyumi
- Department of Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA, USA
| | - Frank M Bengel
- Department of Nuclear Medicine, Hannover Medical School, Hannover, Germany
| | - J Douglas Bremner
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA; Atlanta VA Medical Center, Decatur, GA, USA; Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Viola Vaccarino
- Department of Medicine (Cardiology), Emory University School of Medicine, Atlanta, GA, USA; Department of Epidemiology, Emory University, Atlanta, GA, USA
| | - Ahmed Tawakol
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Boston, MA, USA; Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Michael T Osborne
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Boston, MA, USA; Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
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7
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Chen X, Gu J, Zhang X. Brain-Heart Axis and the Inflammatory Response: Connecting Stroke and Cardiac Dysfunction. Cardiology 2024; 149:369-382. [PMID: 38574466 PMCID: PMC11309082 DOI: 10.1159/000538409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 03/12/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND In recent years, the mechanistic interaction between the brain and heart has been explored in detail, which explains the effects of brain injuries on the heart and those of cardiac dysfunction on the brain. Brain injuries are the predominant cause of post-stroke deaths, and cardiac dysfunction is the second leading cause of mortality after stroke onset. SUMMARY Several studies have reported the association between brain injuries and cardiac dysfunction. Therefore, it is necessary to study the influence on the heart post-stroke to understand the underlying mechanisms of stroke and cardiac dysfunction. This review focuses on the mechanisms and the effects of cardiac dysfunction after the onset of stroke (ischemic or hemorrhagic stroke). KEY MESSAGES The role of the site of stroke and the underlying mechanisms of the brain-heart axis after stroke onset, including the hypothalamic-pituitary-adrenal axis, inflammatory and immune responses, brain-multi-organ axis, are discussed.
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Affiliation(s)
- Xiaosheng Chen
- Department of Neurosurgery, The Affiliated People's Hospital of Ningbo University, Ningbo, China
| | - Jiajie Gu
- Department of Neurosurgery, The Affiliated People's Hospital of Ningbo University, Ningbo, China
| | - Xiaojia Zhang
- Department of Neurosurgery, The Affiliated People's Hospital of Ningbo University, Ningbo, China
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8
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Arsava EM, Chang K, Tawakol A, Loggia ML, Goldstein JN, Brown J, Park KY, Singhal AB, Kalpathy-Cramer J, Sorensen AG, Rosen BR, Samuels MA, Ay H. Stroke-Related Visceral Alterations: A Voxel-Based Neuroanatomic Localization Study. Ann Neurol 2023; 94:1155-1163. [PMID: 37642641 PMCID: PMC10841239 DOI: 10.1002/ana.26785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 08/28/2023] [Accepted: 08/28/2023] [Indexed: 08/31/2023]
Abstract
OBJECTIVE Functional and morphologic changes in extracranial organs can occur after acute brain injury. The neuroanatomic correlates of such changes are not fully known. Herein, we tested the hypothesis that brain infarcts are associated with cardiac and systemic abnormalities (CSAs) in a regionally specific manner. METHODS We generated voxelwise p value maps of brain infarcts for poststroke plasma cardiac troponin T (cTnT) elevation, QTc prolongation, in-hospital infection, and acute stress hyperglycemia (ASH) in 1,208 acute ischemic stroke patients prospectively recruited into the Heart-Brain Interactions Study. We examined the relationship between infarct location and CSAs using a permutation-based approach and identified clusters of contiguous voxels associated with p < 0.05. RESULTS cTnT elevation not attributable to a known cardiac reason was detected in 5.5%, QTc prolongation in the absence of a known provoker in 21.2%, ASH in 33.9%, and poststroke infection in 13.6%. We identified significant, spatially segregated voxel clusters for each CSA. The clusters for troponin elevation and QTc prolongation mapped to the right hemisphere. There were 3 clusters for ASH, the largest of which was in the left hemisphere. We found 2 clusters for poststroke infection, one associated with pneumonia in the left and one with urinary tract infection in the right hemisphere. The relationship between infarct location and CSAs persisted after adjusting for infarct volume. INTERPRETATION Our results show that there are discrete regions of brain infarcts associated with CSAs. This information could be used to bootstrap toward new markers for better differentiation between neurogenic and non-neurogenic mechanisms of poststroke CSAs. ANN NEUROL 2023;94:1155-1163.
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Affiliation(s)
- Ethem Murat Arsava
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown MA, USA
| | - Ken Chang
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown MA, USA
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ahmed Tawakol
- Cardiology Division and Cardiovascular Imaging Research Center, Massachusetts General Hospital, Boston MA, USA
| | - Marco L. Loggia
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown MA, USA
| | - Joshua N. Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - James Brown
- School of Computer Science, University of Lincoln, Lincoln, United Kingdom
| | - Kwang-Yeol Park
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown MA, USA
- Department of Neurology, Chung-Ang University Hospital, Seoul, Republic of Korea
| | - Aneesh B. Singhal
- Department of Neurology, Massachusetts General Hospital, Boston MA, USA
| | - Jayashree Kalpathy-Cramer
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown MA, USA
| | - Alma Gregory Sorensen
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown MA, USA
| | - Bruce R. Rosen
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown MA, USA
| | | | - Hakan Ay
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown MA, USA
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Desai R, Mondal A, Prasad A, Vyas A, Jain A, Rupareliya C, Shah M, Paul T, Kumar G, Sachdeva R. Concurrent Cardio-Cerebral Infarctions in COVID-19: A Systematic Review of Published Case Reports/Series. Curr Probl Cardiol 2023; 48:101814. [PMID: 37209804 PMCID: PMC10193814 DOI: 10.1016/j.cpcardiol.2023.101814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 05/13/2023] [Indexed: 05/22/2023]
Abstract
Twelve CCI patients were studied with confirmed or suspected COVID-19 infection. The majority of these patients were males (83.3%) with a median age of 55 years from three geographical locations, constituting the Middle East (7), Spain (3), and the USA (1). In 6 patients, IgG/IgM was positive for COVID-19, 4 with high pretest probability and 2 with positive RT-PCR. Type 2 DM, hyperlipidemia, and smoking were the primary risk factors. Right-sided neurological impairments and verbal impairment were the most common symptoms. Our analysis found 8 (66%) synchronous occurrences. In 58.3% of cases, neuroimaging showed left Middle Cerebral Artery (MCA) infarct and 33.3% right. Carotid artery thrombosis (16.6%), tandem occlusion (8.3%), and carotid stenosis (1%) were also reported in imaging. Dual antiplatelet therapy (DAPT) and anticoagulants were conservative therapies (10). Two AMI patients had aspiration thrombectomy, while three AIS patients had intravenous thrombolysis/tissue plasminogen activator (IVT-tPA), 2 had mechanical thrombectomy (MT), and 1 had decompressive craniotomy. Five had COVID-19-positive chest X-rays, whereas 4 were normal. four of 8 STEMI and 3 NSTEMI/UA patients complained chest pain. LV, ICA, and pulmonary embolism were further complications (2). Upon discharge, 7 patients (70%) had residual deficits while 1 patient unfortunately died.
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Affiliation(s)
- Rupak Desai
- Division of Cardiology, Atlanta VA Medical Center, Decatur, GA.
| | - Avilash Mondal
- Department of Internal Medicine, Nazareth Hospital, Philadelphia, PA
| | | | - Ankit Vyas
- Department of Internal Medicine, Baptist Hospitals of Southeast Texas, Beaumont, TX
| | - Akhil Jain
- Department of Internal Medicine, Mercy Catholic Medical Center, Darby, PA
| | - Chintan Rupareliya
- Department of Vascular Neurology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Manan Shah
- Department of Neurocritical Care, Department of Neurology and Neurosurgery, Medical College of Georgia at Augusta University, Augusta, GA
| | - Timir Paul
- Division of Cardiology, University of Tennessee Health Sciences Center at Nashville, Saint Thomas Heart Institute, Nashville, TN
| | - Gautam Kumar
- Division of Cardiology, Atlanta VA Medical Center, Decatur, GA; Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Rajesh Sachdeva
- Division of Cardiology, Atlanta VA Medical Center, Decatur, GA
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10
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Abohashem S, Grewal SS, Tawakol A, Osborne MT. Radionuclide Imaging of Heart-Brain Connections. Cardiol Clin 2023; 41:267-275. [PMID: 37003682 PMCID: PMC10152492 DOI: 10.1016/j.ccl.2023.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
The heart and brain have a complex interplay wherein disease or injury to either organ may adversely affect the other. The mechanisms underlying this connection remain incompletely characterized. However, nuclear molecular imaging is uniquely suited to investigate these pathways by facilitating the simultaneous assessment of both organs using targeted radiotracers. Research within this paradigm has demonstrated important roles for inflammation, autonomic nervous system and neurohormonal activity, metabolism, and perfusion in the heart-brain connection. Further mechanistic clarification may facilitate greater clinical awareness and the development of targeted therapies to alleviate the burden of disease in both organs.
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Affiliation(s)
- Shady Abohashem
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Massachusetts General Hospital, Cardiovascular Imaging Research Center, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
| | - Simran S Grewal
- Massachusetts General Hospital, Cardiovascular Imaging Research Center, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA; Division of Cardiology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Ahmed Tawakol
- Massachusetts General Hospital, Cardiovascular Imaging Research Center, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA; Division of Cardiology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Michael T Osborne
- Massachusetts General Hospital, Cardiovascular Imaging Research Center, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA; Division of Cardiology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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11
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Structural and Functional Brain Changes in Acute Takotsubo Syndrome. JACC. HEART FAILURE 2023; 11:307-317. [PMID: 36752489 DOI: 10.1016/j.jchf.2022.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/14/2022] [Accepted: 11/03/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Takotsubo syndrome mimics an acute myocardial infarction, typically in the aftermath of mental or physical stress. OBJECTIVES The mechanism by which emotional processing in the context of stress leads to significant cardiac injury is poorly understood, so a full exploration of brain structure and function in takotsubo syndrome patients merits investigation. METHODS Twenty-five acute (<5 days) takotsubo patients and 25 control subjects were recruited into this observational cross-sectional study. Surface-based morphometry was carried out on magnetic resonance imaging (MRI) brain scans to extract cortical morphology based on volume, thickness, and surface area with the use of Freesurfer. Cortical morphology general linear models were corrected for age, sex, photoperiod, and total brain volume. Resting-state functional MRI and diffusion tensor tractography images were preprocessed and analyzed with the use of the Functional Magnetic Resonance Imaging of the Brain Diffusion Toolbox and Functional Connectivity Toolbox. RESULTS There was significantly smaller total white matter and subcortical gray matter volumes in takotsubo (P < 0.001), with smaller total brain surface area but increased total cortical thickness (both P < 0.001). Individual gray matter regions (hippocampus and others) were significantly smaller in takotsubo (P < 0.001); only thalamus and insula were larger (P < 0.001). There was significant hyperfunctional and hypofunctional connectivity in multiple areas, including thalamus-amygdala-insula and basal ganglia (P < 0.05). All structural tractography connections were increased in takotsubo (P < 0.05). CONCLUSIONS The authors showed smaller gray and white matter volumes driven by smaller cortical surface area, but increased cortical thickness and structural tractography connections with bidirectional changes in functional connectivity linked to emotion, language, reasoning, perception, and autonomic control. These are interventional targets in takotsubo patients' rehabilitation.
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12
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Ziaka M, Exadaktylos A. The Heart Is at Risk: Understanding Stroke-Heart-Brain Interactions with Focus on Neurogenic Stress Cardiomyopathy-A Review. J Stroke 2023; 25:39-54. [PMID: 36592971 PMCID: PMC9911836 DOI: 10.5853/jos.2022.02173] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 11/04/2022] [Accepted: 11/14/2022] [Indexed: 01/04/2023] Open
Abstract
In recent years, it has been convincingly demonstrated that acute brain injury may cause severe cardiac complications-such as neurogenic stress cardiomyopathy (NSC), a specific form of takotsubo cardiomyopathy. The pathophysiology of these brain-heart interactions is complex and involves sympathetic hyperactivity, activation of the hypothalamic-pituitary-adrenal axis, as well as immune and inflammatory pathways. There have been great strides in our understanding of the axis from the brain to the heart in patients with isolated acute brain injury and more specifically in patients with stroke. On the other hand, in patients with NSC, research has mainly focused on hemodynamic dysfunction due to arrhythmias, regional wall motion abnormality, or left ventricular hypokinesia that leads to impaired cerebral perfusion pressure. Comparatively little is known about the underlying secondary and delayed cerebral complications. The aim of the present review is to describe the stroke-heart-brain axis and highlight the main pathophysiological mechanisms leading to secondary and delayed cerebral injury in patients with concurrent hemorrhagic or ischemic stroke and NSC as well as to identify further areas of research that could potentially improve outcomes in this specific patient population.
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Affiliation(s)
- Mairi Ziaka
- Department of Internal Medicine, Thun General Hospital, Thun, Switzerland
| | - Aristomenis Exadaktylos
- Department of Emergency Medicine, Inselspital, University Hospital, University of Bern, Bern, Switzerland
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13
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Cao X, Wei M, Tang M, Jian Z, Liu H, Yue X, Luo G, Sun C, Guo F. Acute Myocardial Infarction and Concomitant Acute Intracranial Hemorrhage: Clinical Characteristics and Outcomes. J Investig Med 2022; 70:1713-1719. [PMID: 35858702 PMCID: PMC9726952 DOI: 10.1136/jim-2022-002334] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2022] [Indexed: 01/25/2023]
Abstract
This study aimed to evaluate the demographic and clinical characteristics, treatments and outcomes of concomitant acute myocardial infarction (AMI) and acute intracranial hemorrhage (ICH). All patients diagnosed with concomitant AMI and acute ICH admitted to our institution were included retrospectively. The patient demographics, clinical characteristics, neuroimaging and treatment approaches were analyzed, and the outcomes of interest included disability as defined by the modified Rankin Scale (mRS) score and all-cause mortality within 1 year of follow-up. Of a total of 4972 patients with AMI, 8 patients (0.2%) with concomitant acute ICH were recruited for the study, including ST-segment elevation myocardial infarction (STEMI, 5 cases) and non-STEMI (3 cases). New-onset acute ICH in 4 of the 5 patients (80%) occurred within 24 hours after the AMI event, and all these patients had a sudden decrease in the level of consciousness, with an average decrease of 4.6 on the Glasgow Coma Scale. All 5 out of 8 patients had irregular shapes and uncommon sites of hematoma presentation documented on CT scans. Unfortunately, 2 patients died from a progression of ICH within 1 week, and 2 of the 6 survivors had poor functional outcomes (mRS ≥3) at the 1-year follow-up. Concomitant acute ICH and AMI are rare complications displaying unique iconography. Acute ICH caused serious prejudice in AMI with higher mortality and poor functional outcomes, and cardiac catheterization without the administration of antithrombotic or antiplatelet agents was feasible for patients who had unstable hemodynamics or STEMI.
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Affiliation(s)
- Xiangqi Cao
- Department of Neurology, Xi'an Jiaotong University Medical College First Affiliated Hospital, Xi'an, Shaanxi, China
| | - Meng Wei
- Department of Neurology, Xi'an Jiaotong University Medical College First Affiliated Hospital, Xi'an, Shaanxi, China
| | - Manyun Tang
- Department of Cardiovascular Medicine, Xi'an Jiaotong University Medical College First Affiliated Hospital, Xi'an, Shaanxi, China
| | - Zhijie Jian
- Department of Medical Radiology, Xi'an Jiaotong University Medical College First Affiliated Hospital, Xi'an, Shaanxi, China
| | - Hui Liu
- Biobank, Xi'an Jiaotong University Medical College First Affiliated Hospital, Xi'an, Shaanxi, China
| | - Xin Yue
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Guogang Luo
- Department of Neurology, Xi'an Jiaotong University Medical College First Affiliated Hospital, Xi'an, Shaanxi, China
| | - Chaofeng Sun
- Department of Cardiovascular Medicine, Xi'an Jiaotong University Medical College First Affiliated Hospital, Xi'an, Shaanxi, China
| | - Fengwei Guo
- Department of Cardiovascular Medicine, Xi'an Jiaotong University Medical College First Affiliated Hospital, Xi'an, Shaanxi, China
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14
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Min J, Young G, Umar A, Kampfschulte A, Ahrar A, Miller M, Khan N, Wees N, Chalfoun N, Khan M. Neurogenic cardiac outcome in patients after acute ischemic stroke: The brain and heart connection. J Stroke Cerebrovasc Dis 2022; 31:106859. [PMID: 36323165 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106859] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/14/2022] [Accepted: 10/20/2022] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Jiangyong Min
- Department of Neurosciences and Comprehensive Stroke Center, Spectrum Health and Michigan State University College of Human Medicine, 25 Michigan Street NE, Suite 6100, Grand Rapids, MI 49503, United States.
| | - Grant Young
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Abdullah Umar
- Stephen M. Ross School of Business, University of Michigan, Ann Arbor, MI, United States
| | - Andrew Kampfschulte
- Offices of Research and Education, Spectrum Health, Grand Rapids, MI, United States
| | - Asad Ahrar
- Department of Neurosciences and Comprehensive Stroke Center, Spectrum Health and Michigan State University College of Human Medicine, 25 Michigan Street NE, Suite 6100, Grand Rapids, MI 49503, United States
| | - Malgorzata Miller
- Department of Neurosciences and Comprehensive Stroke Center, Spectrum Health and Michigan State University College of Human Medicine, 25 Michigan Street NE, Suite 6100, Grand Rapids, MI 49503, United States
| | - Nadeem Khan
- Department of Neurosciences and Comprehensive Stroke Center, Spectrum Health and Michigan State University College of Human Medicine, 25 Michigan Street NE, Suite 6100, Grand Rapids, MI 49503, United States
| | - Nabil Wees
- Department of Neurosciences and Comprehensive Stroke Center, Spectrum Health and Michigan State University College of Human Medicine, 25 Michigan Street NE, Suite 6100, Grand Rapids, MI 49503, United States
| | - Nagib Chalfoun
- Department of Cardiovascular Medicine, Frederik Meijer Heart and Vascular Institute, Spectrum Health and Michigan State University College of Human Medicine, Grand Rapids, MI, United States
| | - Muhib Khan
- Department of Neurosciences and Comprehensive Stroke Center, Spectrum Health and Michigan State University College of Human Medicine, 25 Michigan Street NE, Suite 6100, Grand Rapids, MI 49503, United States
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15
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Limonova AS, Germanova KN, Gantman MV, Nazarova MA, Davtyan KV, Novikov PA, Sukmanova AA, Tarasov AV, Kharlap MS, Ershova AI, Drapkina OM. Neurovisceral interactions within the brain-heart axis as the basis of neurocardiology. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2022. [DOI: 10.15829/1728-8800-2022-3435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The use of a systematic approach to the study of the etiology of a certain pathology makes it possible to improve the understanding of its pathogenesis, as well as to develop more effective diagnostic and therapeutic approaches, including improving the prediction of its risk. Within this review, we will consider such an area of interdisciplinary research as neurocardiology, which studies the brain-heart axis. Examples of cardiovascular diseases associated with organic and functional disorders of this axis will be considered, as well as the prospects for research in this area and their translational significance for clinical medicine.
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Affiliation(s)
- A. S. Limonova
- National Medical Research Center for Therapy and Preventive Medicine
| | - K. N. Germanova
- National Medical Research Center for Therapy and Preventive Medicine; National Research University Higher School of Economics
| | - M. V. Gantman
- National Research University Higher School of Economics
| | - M. A. Nazarova
- National Research University Higher School of Economics; Harvard Medical School
| | - K. V. Davtyan
- National Medical Research Center for Therapy and Preventive Medicine
| | - P. A. Novikov
- National Research University Higher School of Economics
| | - A. A. Sukmanova
- National Medical Research Center for Therapy and Preventive Medicine; National Research University Higher School of Economics
| | - A. V. Tarasov
- National Medical Research Center for Therapy and Preventive Medicine
| | - M. S. Kharlap
- National Medical Research Center for Therapy and Preventive Medicine
| | - A. I. Ershova
- National Medical Research Center for Therapy and Preventive Medicine
| | - O. M. Drapkina
- National Medical Research Center for Therapy and Preventive Medicine
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16
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Steiger R, Tuovinen N, Adukauskaite A, Senoner T, Spitaler P, Bilgeri V, Dabkowska-Mika A, Siedentopf C, Bauer A, Gizewski ER, Hofer A, Barbieri F, Dichtl W. Limbic Responses to Aversive Visual Stimuli during the Acute and Recovery Phase of Takotsubo Syndrome. J Clin Med 2022; 11:jcm11164891. [PMID: 36013130 PMCID: PMC9410353 DOI: 10.3390/jcm11164891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/13/2022] [Accepted: 08/18/2022] [Indexed: 11/23/2022] Open
Abstract
The role of the limbic system in the acute phase and during the recovery of takotsubo syndrome needs further clarification. In this longitudinal study, anatomical and task-based functional magnetic resonance imaging of the brain was performed during an emotional picture paradigm in 19 postmenopausal female takotsubo syndrome patients in the acute and recovery phases in comparison to sex- and aged-matched 15 healthy controls and 15 patients presenting with myocardial infarction. Statistical analyses were performed based on the general linear model where aversive and positive picture conditions were included in order to reveal group differences during encoding of aversive versus positive pictures and longitudinal changes. In the acute phase, takotsubo syndrome patients showed a lower response in regions involved in affective and cognitive emotional processes (e.g., insula, thalamus, frontal cortex, inferior frontal gyrus) while viewing aversive versus positive pictures compared to healthy controls and patients presenting with myocardial infarction. In the recovery phase, the response in these brain regions normalized in takotsubo syndrome patients to the level of healthy controls, whereas patients 8–12 weeks after myocardial infarction showed lower responses in the limbic regions (mainly in the insula, frontal regions, thalamus, and inferior frontal gyrus) compared to healthy controls and takotsubo syndrome patients. In conclusion, compared to healthy controls and patients suffering from acute myocardial infarction, limbic responses to aversive visual stimuli are attenuated during the acute phase of takotsubo syndrome, recovering within three months. Reduced functional brain responses in the recovery phase after a myocardial infarction need further investigation.
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Affiliation(s)
- Ruth Steiger
- University Hospital for Neuroradiology, Medical University of Innsbruck, 6020 Innsbruck, Austria
- Neuroimaging Research Core Facility, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Noora Tuovinen
- Division of Psychiatry I, University Hospital for Psychiatry, Psychotherapy, Psychosomatics and Medical Psychology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Agne Adukauskaite
- University Hospital for Internal Medicine III (Cardiology and Angiology), Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Thomas Senoner
- University Hospital for Internal Medicine III (Cardiology and Angiology), Medical University of Innsbruck, 6020 Innsbruck, Austria
- University Hospital for Anesthesiology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Philipp Spitaler
- University Hospital for Internal Medicine III (Cardiology and Angiology), Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Valentin Bilgeri
- University Hospital for Internal Medicine III (Cardiology and Angiology), Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Agnieszka Dabkowska-Mika
- University Hospital for Neuroradiology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Christian Siedentopf
- University Hospital for Neuroradiology, Medical University of Innsbruck, 6020 Innsbruck, Austria
- Neuroimaging Research Core Facility, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Axel Bauer
- University Hospital for Internal Medicine III (Cardiology and Angiology), Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Elke Ruth Gizewski
- University Hospital for Neuroradiology, Medical University of Innsbruck, 6020 Innsbruck, Austria
- Neuroimaging Research Core Facility, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Alex Hofer
- Division of Psychiatry I, University Hospital for Psychiatry, Psychotherapy, Psychosomatics and Medical Psychology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Fabian Barbieri
- University Hospital for Internal Medicine III (Cardiology and Angiology), Medical University of Innsbruck, 6020 Innsbruck, Austria
- University Hospital for Cardiology, Charité—Campus Benjamin Franklin, 12203 Berlin, Germany
| | - Wolfgang Dichtl
- University Hospital for Internal Medicine III (Cardiology and Angiology), Medical University of Innsbruck, 6020 Innsbruck, Austria
- Correspondence: ; Tel.: +43-512-504-81388
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17
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Nagai M, Förster CY, Dote K. Sex Hormone-Specific Neuroanatomy of Takotsubo Syndrome: Is the Insular Cortex a Moderator? Biomolecules 2022; 12:biom12010110. [PMID: 35053258 PMCID: PMC8773903 DOI: 10.3390/biom12010110] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 01/06/2022] [Indexed: 02/04/2023] Open
Abstract
Takotsubo syndrome (TTS), a transient form of dysfunction in the heart’s left ventricle, occurs predominantly in postmenopausal women who have emotional stress. Earlier studies support the concept that the human circulatory system is modulated by a cortical network (consisting of the anterior cingulate gyrus, amygdala, and insular cortex (Ic)) that plays a pivotal role in the central autonomic nervous system in relation to emotional stressors. The Ic plays a crucial role in the sympathovagal balance, and decreased levels of female sex hormones have been speculated to change functional cerebral asymmetry, with a possible link to autonomic instability. In this review, we focus on the Ic as an important moderator of the human brain–heart axis in association with sex hormones. We also summarize the current knowledge regarding the sex-specific neuroanatomy in TTS.
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Affiliation(s)
- Michiaki Nagai
- Department of Cardiology, Hiroshima City Asa Hospital, Hiroshima 731-0293, Japan;
- Correspondence: ; Tel.: +81-82-815-5211; Fax: +81-82-814-1791
| | - Carola Yvette Förster
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University of Würzburg, D-97080 Würzburg, Germany;
| | - Keigo Dote
- Department of Cardiology, Hiroshima City Asa Hospital, Hiroshima 731-0293, Japan;
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18
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Molecular imaging of the brain-heart axis provides insights into cardiac dysfunction after cerebral ischemia. Basic Res Cardiol 2022; 117:52. [PMID: 36279013 PMCID: PMC9592646 DOI: 10.1007/s00395-022-00961-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 09/26/2022] [Accepted: 10/13/2022] [Indexed: 01/31/2023]
Abstract
Ischemic stroke imparts elevated risk of heart failure though the underlying mechanisms remain poorly described. We aimed to characterize the influence of cerebral ischemic injury on cardiac function using multimodality molecular imaging to investigate brain and cardiac morphology and tissue inflammation in two mouse models of variable stroke severity. Transient middle cerebral artery occlusion (MCAo) generated extensive stroke damage (56.31 ± 40.39 mm3). Positron emission tomography imaging of inflammation targeting the mitochondrial translocator protein (TSPO) revealed localized neuroinflammation at 7 days after stroke compared to sham (3.8 ± 0.8 vs 2.6 ± 0.7 %ID/g max, p < 0.001). By contrast, parenchyma topical application of vasoconstrictor endothelin-1 did not generate significant stroke damage or neuroinflammatory cell activity. MCAo evoked a modest reduction in left ventricle ejection fraction at both 1 weeks and 3 weeks after stroke (LVEF at 3 weeks: 54.3 ± 5.7 vs 66.1 ± 3.5%, p < 0.001). This contractile impairment was paralleled by elevated cardiac TSPO PET signal compared to sham (8.6 ± 2.4 vs 5.8 ± 0.7%ID/g, p = 0.022), but was independent of leukocyte infiltration defined by flow cytometry. Stroke size correlated with severity of cardiac dysfunction (r = 0.590, p = 0.008). Statistical parametric mapping identified a direct association between neuroinflammation at 7 days in a cluster of voxels including the insular cortex and reduced ejection fraction (ρ = - 0.396, p = 0.027). Suppression of microglia led to lower TSPO signal at 7 days which correlated with spared late cardiac function after MCAo (r = - 0.759, p = 0.029). Regional neuroinflammation early after cerebral ischemia influences subsequent cardiac dysfunction. Total body TSPO PET enables monitoring of neuroinflammation, providing insights into brain-heart inter-organ communication and may guide therapeutic intervention to spare cardiac function post-stroke.
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19
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Li J, Zhang P, Liu Y, Chen W, Yi X, Wang C. Stroke Lateralization in Large Hemisphere Infarctions: Characteristics, Stroke-Related Complications, and Outcomes. Front Neurol 2021; 12:774247. [PMID: 34956055 PMCID: PMC8702425 DOI: 10.3389/fneur.2021.774247] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 11/05/2021] [Indexed: 12/28/2022] Open
Abstract
Objectives: To assess the hemispheric differences in characteristics, stroke-related complications, and outcomes of patients with large hemisphere infarctions (LHI). Methods: We enrolled consecutive patients admitted within 24 h after the diagnosis of LHI (defined as an ischemic stroke involving more than 50% of the territory of the middle cerebral artery in computed tomography and/or magnetic resonance imaging). Univariate and multivariate analysis were performed to explore the association between lateralization and stroke-related complications and clinical outcomes. Results: A total of 314 patients with LHI were enrolled, with 171 (54.5%) having right hemispheric involvement. Right-sided patients with LHI had lower baseline National Institutes of Health Stroke Scale (NIHSS) score (18 vs. 22, p < 0.001), higher frequency of atrial fibrillation (69.0 vs. 52.4%, p = 0.003), and higher proportion of cardio-embolism (73.1 vs. 56.6%, p = 0.013) than the left. Right-sided LHI had higher incidence rates of malignant brain edema (MBE) (48.5 vs. 30.8%, p = 0.001) and a composite of cardiovascular events (29.8 vs. 17.5%, p = 0.011) during hospitalization. The incidence rate of 1-month mortality (34.5 vs. 23.8%, p = 0.036) was higher in right-sided patients with LHI, but there were no hemispheric differences in the incidence rates of 3-month mortality and unfavorable outcome (both p > 0.05). Multivariate analyses suggested right hemisphere involvement was independently associated with increased risk of MBE (adjusted OR 2.37, 95% CI 1.26–4.43, p = 0.007) and composite of cardiovascular events (adjusted OR 2.04, 95% CI 1.12–3.72, p = 0.020). However, it was not independently associated with 1-month death, 3-month mortality, and 3-month unfavorable outcome (all p > 0.05). Conclusions: Right-sided patients with LHI had higher frequency of atrial fibrillation and cardio-embolism than the left-sided patients. Right hemisphere involvement was independently associated with increased risk of MBE and composite of cardiovascular events during hospitalization, whereas stroke lateralization was not an independent predictor of mortality and unfavorable outcome in patients with LHI.
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Affiliation(s)
- Jie Li
- Department of Neurology, People's Hospital of Deyang, Deyang, China
| | - Ping Zhang
- Department of Neurology, People's Hospital of Deyang, Deyang, China
| | - Yingying Liu
- Department of Neurology, People's Hospital of Deyang, Deyang, China
| | - Wanli Chen
- Department of Neurology, People's Hospital of Deyang, Deyang, China
| | - Xingyang Yi
- Department of Neurology, People's Hospital of Deyang, Deyang, China
| | - Chun Wang
- Department of Neurology, People's Hospital of Deyang, Deyang, China
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20
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Marto JP, Kauppila LA, Jorge C, Faustino P, Sargento-Freitas J, Pereira L, Galego S, Dias R, Castro P, Pinho-E-Melo T, Fonseca AC. Acute Myocardial Infarction after Intravenous Thrombolysis for Acute Ischemic Stroke: Case Series and Systematic Review. J Stroke Cerebrovasc Dis 2021; 31:106244. [PMID: 34915306 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106244] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/19/2021] [Accepted: 11/23/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Intravenous thrombolysis (IV-rtPA) has been suggested as a potential cause of myocardial infarction (MI) after acute ischemic stroke (AIS), with randomized clinical trials showing a higher number of cardiac events within the thrombolysis group. We assessed the prevalence and MI mechanisms after IV-rtPA for AIS. METHODS Retrospective review of consecutive AIS patients admitted to six stroke units and systematic literature review searching for AIS patients who suffered a MI less than 24 h after IV-rtPA. In those with available coronary angiography, MI etiology was defined as atherosclerotic or embolic. Patients' characteristics were compared between groups. RESULTS Fifty-two patients were included. Thirty-two patients (61.5%) derived from hospital cases, after reviewing 6958 patients treated with IV-rtPA [0.5% (95% CI 0.38-0.54) of total hospital cases]. After coronary angiography (n = 25, 48.1%), 14 (54%) patients were considered to have an atherosclerotic MI, and 11 (46%) due to coronary embolism. Patients with an embolic MI more frequently had a cardioembolic AIS (72.7% vs 28.6%; p-value = 0.047) and an intracardiac thrombus (27.3% vs 0.0%; p-value = 0.044). Although not statistically significant, patients with an embolic MI had apparent lower time intervals between starting IV-rtPA infusion and MI occurrence [2 h (0.2-3.0) vs 3 h (1.0-15.0); p-value = 0.134]. CONCLUSIONS MI within the first 24 h after IV-rtPA for AIS is an infrequent event, and more frequently non-embolic. However, the prevalence of embolic MI was superior to what is found in the general population with MI. There was an association between the pathophysiology of AIS and MI. The low number of events and publication bias may have limited our conclusions.
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Affiliation(s)
- João Pedro Marto
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Rua da Junqueira, n°126, Lisbon 1349-019, Portugal; CEDOC, NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal.
| | - Linda Azevedo Kauppila
- Neurology, Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitário de Lisboa Norte, Lisbon, Portugal
| | - Cláudia Jorge
- Department of Cardiology, Hospital de Santa Maria, Centro Hospitalar Universitário de Lisboa Norte, Lisbon, Portugal
| | - Pedro Faustino
- Department of Neurology, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - João Sargento-Freitas
- Department of Neurology, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Liliana Pereira
- Department of Neurology, Hospital Garcia de Orta, Almada, Portugal
| | - Sofia Galego
- Stroke Unit, Hospital São José, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Rafael Dias
- Department of Neurology, Hospital Central do Funchal, Funchal, Portugal; Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Pedro Castro
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Teresa Pinho-E-Melo
- Stroke Unit and Neurology, Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitário de Lisboa Norte, Lisbon, Portugal; Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Ana Catarina Fonseca
- Stroke Unit and Neurology, Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitário de Lisboa Norte, Lisbon, Portugal; Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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Bithal PK, Jan R, Kumar B, Rahman IU. Left Frontal Lobe Tumor-Induced Intraoperative Premature Ventricular Beats. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2021. [DOI: 10.1055/s-0041-1731978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
AbstractIn the absence of cardiac pathology, premature ventricular contractions (PVCs) in neurosurgical patients frequently accompany subarachnoid hemorrhage, intracerebral hemorrhage, traumatic brain injury, or raised intracranial pressure. PVCs detected during preanesthesia assessment prompts detailed cardiac evaluation. Our 57-year-old patient, a case of left frontal meningioma, with controlled hypertension, diabetes and hypothyroidism, had normal preoperative ECG and potassium. However, immediately on anesthesia induction, she developed multiple refractory to treatment PVCs but with normal blood pressure. Anesthesia, which was maintained with sevoflurane and fentanyl, was deepened to exclude light anesthesia as the cause, without useful outcome. Two lignocaine boluses (100 mg each), followed by its infusion, also proved ineffective. Her blood gases and potassium, checked twice, were normal. Throughout, her hemodynamics remained stable. As soon as tumor was removed, the PVCs disappeared not to return. Her postoperative recovery was uneventful with normal ECG.
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Affiliation(s)
- Parmod K. Bithal
- Department of Anesthesia and Perioperative Medicine, King Fahad Medical City Riyadh, Riyadh, Saudi Arabia
| | - Ravees Jan
- Department of Anesthesia and Perioperative Medicine, King Fahad Medical City Riyadh, Riyadh, Saudi Arabia
| | - Bharani Kumar
- Department of Anesthesia and Perioperative Medicine, King Fahad Medical City Riyadh, Riyadh, Saudi Arabia
| | - Insha ur Rahman
- Department of Anesthesia and Perioperative Medicine, King Fahad Medical City Riyadh, Riyadh, Saudi Arabia
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Cardio-cerebral infarction in left MCA strokes: a case series and literature review. Neurol Sci 2021; 43:2413-2422. [PMID: 34590206 PMCID: PMC8480750 DOI: 10.1007/s10072-021-05628-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 09/23/2021] [Indexed: 10/27/2022]
Abstract
The objective of this manuscript is to describe the challenges of Cardio-Cerebral Infarction (CCI) treatment and to highlight the variable approaches in management. CCI is a rare clinical presentation of simultaneous acute ischemic stroke (AIS) and acute myocardial infarction (AMI) and poses a therapeutic challenge for practitioners. Each disease requires timely intervention to prevent irreversible damage; however, optimal management remains unclear. We describe three cases of CCI. All three patients presented with symptomatic left MCA (M1) occlusion, with ST elevation myocardial infarction (STEMI) and left ventricular apical thrombus. Fibrinolysis and mechanical thrombectomy (MT) were discussed in all cases, but only one patient received alteplase (0.9 mg/kg) and none underwent MT. Percutaneous intervention (PCI) was done in only one case. The two patients that did not receive thrombolysis were treated with modified therapeutic heparin (no bolus), and all received antiplatelet therapy. Ultimately, all three patients passed away. CCI poses a clinical challenge for physicians including (1) optimal strategies to enable swift mechanical reperfusion to both the brain and myocardium; (2) difference in dosage of thrombolytics for AIS versus AMI; (3) risk of symptomatic intracerebral hemorrhage following administration of anticoagulation and/or antiplatelet therapy; and (4) caution with use of thrombolytics in the setting of acute STEMI due to the risk of myocardial rupture. In the absence of high quality evidence and clinical guidelines, treatment of CCI is highly individualized.
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Marins FR, Oliveira AC, Qadri F, Motta-Santos D, Alenina N, Bader M, Fontes MAP, Santos RAS. Alamandine but not angiotensin-(1-7) produces cardiovascular effects at the rostral insular cortex. Am J Physiol Regul Integr Comp Physiol 2021; 321:R513-R521. [PMID: 34346721 DOI: 10.1152/ajpregu.00308.2020] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 07/28/2021] [Indexed: 11/22/2022]
Abstract
Experiments aimed to evaluate the tissue distribution of Mas-related G protein-coupled receptor D (MrgD) revealed the presence of immunoreactivity for the MrgD protein in the rostral insular cortex (rIC), an important area for autonomic and cardiovascular control. To investigate the relevance of this finding, we evaluated the cardiovascular effects produced by the endogenous ligand of MrgD, alamandine, in this brain region. Mean arterial pressure (MAP), heart rate (HR), and renal sympathetic nerve activity (RSNA) were recorded in urethane anesthetized rats. Unilateral microinjection of equimolar doses of alamandine (40 pmol/100 nL), angiotensin-(1-7), angiotensin II, angiotensin A, and Mas/MrgD antagonist d-Pro7-Ang-1-7 (50 pmol/100 nL), Mas antagonist A779 (100 pmol/100 nL), or vehicle (0.9% NaCl) were made in different rats (n = 4-6/group) into rIC. To verify the specificity of the region, a microinjection of alamandine was also performed into intermediate insular cortex (iIC). Microinjection of alamandine in rIC produced an increase in MAP (Δ = 15 ± 2 mmHg), HR (Δ = 36 ± 4 beats/min), and RSNA (Δ = 31 ± 4%), but was without effects at iIC. Strikingly, an equimolar dose of angiotensin-(1-7) at rIC did not produce any change in MAP, HR, and RSNA. Angiotensin II and angiotensin A produced only minor effects. Alamandine effects were not altered by A-779, a Mas antagonist, but were completely blocked by the Mas/MrgD antagonist d-Pro7-Ang-(1-7). Therefore, we have identified a brain region in which alamandine/MrgD receptor but not angiotensin-(1-7)/Mas could be involved in the modulation of cardiovascular-related neuronal activity. This observation also suggests that alamandine might possess unique effects unrelated to angiotensin-(1-7) in the brain.
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Affiliation(s)
- Fernanda Ribeiro Marins
- Laboratório de Hipertensão, Department of Physiology and Biophysics, Institute of Biological Sciences, National Institute of Science and Technology in Nanobiopharmaceutics, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Aline Cristina Oliveira
- Laboratório de Hipertensão, Department of Physiology and Biophysics, Institute of Biological Sciences, National Institute of Science and Technology in Nanobiopharmaceutics, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | | | - Daisy Motta-Santos
- Laboratório de Hipertensão, Department of Physiology and Biophysics, Institute of Biological Sciences, National Institute of Science and Technology in Nanobiopharmaceutics, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Natalia Alenina
- Max-Delbrück Center for Molecular Medicine, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Michael Bader
- Max-Delbrück Center for Molecular Medicine, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Institute for Biology, University of Lübeck, Lübeck, Germany
- Charité University Medicine, Berlin, Germany
| | - Marco Antonio Peliky Fontes
- Laboratório de Hipertensão, Department of Physiology and Biophysics, Institute of Biological Sciences, National Institute of Science and Technology in Nanobiopharmaceutics, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Robson Augusto Souza Santos
- Laboratório de Hipertensão, Department of Physiology and Biophysics, Institute of Biological Sciences, National Institute of Science and Technology in Nanobiopharmaceutics, Federal University of Minas Gerais, Belo Horizonte, Brazil
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Reisert M, Weiller C, Hosp JA. Displaying the autonomic processing network in humans - a global tractography approach. Neuroimage 2021; 231:117852. [PMID: 33582271 DOI: 10.1016/j.neuroimage.2021.117852] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/11/2021] [Accepted: 02/05/2021] [Indexed: 12/12/2022] Open
Abstract
Regulation of the internal homeostasis is modulated by the central autonomic system. So far, the view of this system is determined by animal and human research focusing on cortical and subcortical grey substance regions. To provide an overview based on white matter architecture, we used a global tractography approach to reconstruct a network of tracts interconnecting brain regions that are known to be involved in autonomic processing. Diffusion weighted imaging data were obtained from subjects of the human connectome project (HCP) database. Resulting tracts are in good agreement with previous studies assuming a division of the central autonomic system into a cortical (CAN) and a subcortical network (SAN): the CAN consist of three subsystems that encompass all cerebral lobes and overlap within the insular cortex: a parieto-anterior-temporal pathway (PATP), an occipito-posterior-temporo-frontal pathway (OPTFP) and a limbic pathway. The SAN on the other hand connects the hypothalamus to the periaqueductal grey and locus coeruleus, before it branches into a dorsal and a lateral part that target autonomic nuclei in the rostral medulla oblongata. Our approach furthermore reveals how the CAN and SAN are interconnected: the hypothalamus can be considered as the interface-structure of the SAN, whereas the insula is the central hub of the CAN. The hypothalamus receives input from prefrontal cortical fields but is also connected to the ventral apex of the insular cortex. Thus, a holistic view of the central autonomic system could be created that may promote the understanding of autonomic signaling under physiological and pathophysiological conditions.
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Affiliation(s)
- M Reisert
- Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Department of Medical Physics, Freiburg University Medical Center, Freiburg, Germany
| | - C Weiller
- Clinic of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - J A Hosp
- Clinic of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany.
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Zeng YY, Zhang WB, Cheng L, Wang L, Geng DD, Tang WJ, He JC, Deng BB. Cardiac parameters affect prognosis in patients with non-large atherosclerotic infarction. Mol Med 2021; 27:2. [PMID: 33407066 PMCID: PMC7788897 DOI: 10.1186/s10020-020-00260-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 12/16/2020] [Indexed: 11/16/2022] Open
Abstract
Background Although large artery atherosclerosis (LAA) is the most common type of cerebral infarction, non-LAA is not uncommon. The purpose of this paper is to investigate the prognosis of patients with non-LAA and to establish a corresponding nomogram. Patients and methods Between June 2016 and June 2017, we had 1101 admissions for acute ischemic stroke (AIS). Of these, 848 were LAA and 253 were non-LAA. Patients were followed up every 3 months with a minimum of 1 year of follow-up. After excluding patients who were lost follow-up and patients who did not meet the inclusion criteria, a total of 152 non-LAA patients were included in this cohort study. After single-factor analysis and multifactor logistic regression analysis, the risk factors associated with prognosis were derived and different nomograms were developed based on these risk factors. After comparison, the best model is derived. Results Logistics regression found that the patient’s National Institutes of Health Stroke Scale (NIHSS) score, ejection fraction (EF), creatine kinase-MB (CK-MB), age, neutrophil-to-lymphocyte ratio (NLR), aspartate aminotransferase (AST), and serum albumin were independently related to the patient’s prognosis. We thus developed three models: model 1: single NIHSS score, AUC = 0.8534; model 2, NIHSS + cardiac parameters (CK-MB, EF), AUC = 0.9325; model 3, NIHSS + CK−MB + EF + age + AST + NLR + albumin, AUC = 0.9598. We compare the three models: model 1 vs model 2, z = − 2.85, p = 0.004; model 2 vs model 3, z = − 1.58, p = 0.122. Therefore, model 2 is considered to be the accurate and convenient model. Conclusions Predicting the prognosis of patients with non-LAA is important, and our nomogram, built on the NIHSS and cardiac parameters, can predict the prognosis accurately and provide a powerful reference for clinical decision making.
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Affiliation(s)
- Ya-Ying Zeng
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.,First School of Clinical Medicine, Wenzhou Medical University, Wenzhou, China
| | - Wen-Bo Zhang
- Department of Neurosurgery, The Children's Hospital of Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Lin Cheng
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.,First School of Clinical Medicine, Wenzhou Medical University, Wenzhou, China
| | - Li Wang
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Dan-Dan Geng
- First School of Clinical Medicine, Wenzhou Medical University, Wenzhou, China
| | - Wen-Jie Tang
- First School of Clinical Medicine, Wenzhou Medical University, Wenzhou, China.
| | - Jin-Cai He
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.
| | - Bin-Bin Deng
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.
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Taborda NP, Besteiro G, Pfirter F. INFARTO SIMULTÁNEO CARDIO-CEREBRAL AGUDO: A PROPÓSITO DE UN CASO. REVISTA MÉDICA CLÍNICA LAS CONDES 2020. [DOI: 10.1016/j.rmclc.2020.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Bengel FM, Hermanns N, Thackeray JT. Radionuclide Imaging of the Molecular Mechanisms Linking Heart and Brain in Ischemic Syndromes. Circ Cardiovasc Imaging 2020; 13:e011303. [DOI: 10.1161/circimaging.120.011303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
For the heart and the brain, clinical observations suggest that an acute ischemic event experienced by one organ is associated with an increased risk for future acute events and chronic dysfunction of the reciprocal organ. Beyond atherosclerosis as a common systemic disease, various molecular mechanisms are thought to be involved in this interaction. Molecular-targeted nuclear imaging may identify the contribution of factors, such as the neurohumoral, circulatory, or especially the immune system, by combining specific radiotracers with whole-body acquisition and global as well as regional multiorgan analysis. This may be integrated with complementary functional imaging markers and systemic biomarkers for comprehensive network interrogation. Such systems-based strategies go beyond the traditional organ-centered approach and provide novel mechanistic insights, information about temporal dynamics, and a foundation for future interventions aiming at optimal preservation of function of both organs.
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Affiliation(s)
- Frank M. Bengel
- Department of Nuclear Medicine, Hannover Medical School, Germany
| | - Nele Hermanns
- Department of Nuclear Medicine, Hannover Medical School, Germany
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Mrozek S, Gobin J, Constantin JM, Fourcade O, Geeraerts T. Crosstalk between brain, lung and heart in critical care. Anaesth Crit Care Pain Med 2020; 39:519-530. [PMID: 32659457 DOI: 10.1016/j.accpm.2020.06.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 05/05/2020] [Accepted: 06/07/2020] [Indexed: 12/17/2022]
Abstract
Extracerebral complications, especially pulmonary and cardiovascular, are frequent in brain-injured patients and are major outcome determinants. Two major pathways have been described: brain-lung and brain-heart interactions. Lung injuries after acute brain damages include ventilator-associated pneumonia (VAP), acute respiratory distress syndrome (ARDS) and neurogenic pulmonary œdema (NPE), whereas heart injuries can range from cardiac enzymes release, ECG abnormalities to left ventricle dysfunction or cardiogenic shock. The pathophysiologies of these brain-lung and brain-heart crosstalk are complex and sometimes interconnected. This review aims to describe the epidemiology and pathophysiology of lung and heart injuries in brain-injured patients with the different pathways implicated and the clinical implications for critical care physicians.
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Affiliation(s)
- Ségolène Mrozek
- Department of anaesthesia and critical care, university hospital of Toulouse, university Toulouse 3 Paul Sabatier, Toulouse, France.
| | - Julie Gobin
- Department of anaesthesia and critical care, university hospital of Toulouse, university Toulouse 3 Paul Sabatier, Toulouse, France
| | - Jean-Michel Constantin
- Department of anaesthesia and critical care, Sorbonne university, La Pitié-Salpêtrière hospital, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Olivier Fourcade
- Department of anaesthesia and critical care, university hospital of Toulouse, university Toulouse 3 Paul Sabatier, Toulouse, France
| | - Thomas Geeraerts
- Department of anaesthesia and critical care, university hospital of Toulouse, university Toulouse 3 Paul Sabatier, Toulouse, France
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Marins FR, Limborço-Filho M, D'Abreu BF, Machado de Almeida PW, Gavioli M, Xavier CH, Oppenheimer SM, Guatimosim S, Fontes MAP. Autonomic and cardiovascular consequences resulting from experimental hemorrhagic stroke in the left or right intermediate insular cortex in rats. Auton Neurosci 2020; 227:102695. [PMID: 32629215 DOI: 10.1016/j.autneu.2020.102695] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/20/2020] [Accepted: 06/21/2020] [Indexed: 11/17/2022]
Abstract
Damage to the insular cortex (IC) results in serious cardiovascular consequences and evidence indicates that the characteristics are lateralized. However, a study comparing the effects of focal experimental hemorrhage between IC sides was never performed. We compared the cardiovascular, autonomic and cardiac changes produced by focal experimental hemorrhage (ICH) into the left (L) or right (R) IC. Wistar rats were submitted to microinjection of autologous blood (ICH) or saline (n = 6 each side/group) into the R or L IC. Blood pressure (BP), heart rate (HR) and renal sympathetic activity (RSNA) were recorded. Measurements of calcium transient and sarcoplasmic Ca2+ ATPase expression in cardiomyocytes were performed. ICH increased baseline HR (Δ:L-ICH 452 ± 13 vs saline 407 ± 11 bpm; R-ICH 450 ± 7 vs saline 406 ± 8 bpm, P < 0.05) without changing BP. HR was restored to baseline levels after i.v. atenolol. Strikingly, ICH rats presented a reduced baseline RSNA (Δ:L-ICH 122 ± 4 vs saline 148 ± 11 spikes/s; R-ICH 112 ± 5 vs saline 148 ± 7 spikes/s, P < 0.05). After 24 h of ICH we observed a marked increase in cardiac ectopies and this number was greater after ICH R-IC. Heart weight, calcium amplitude and SERCA expression were reduced only in ICH R-IC. Focal stroke into IC can alter the cardiac and renal autonomic control. Damage to the R-IC produces a greater number of arrhythmias and changes in calcium dynamics in cardiac cells indicating that the cardiovascular consequences are hemisphere-dependent. These findings confirm asymmetry for cardiac autonomic control at the IC and help to understand the cardiac and renal implications observed after specific side cortical damage.
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Affiliation(s)
- Fernanda Ribeiro Marins
- Departamento de Fisiologia & Biofísica, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Marcelo Limborço-Filho
- Departamento de Fisiologia & Biofísica, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Bárbara Flecha D'Abreu
- Departamento de Fisiologia & Biofísica, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Pedro W Machado de Almeida
- Departamento de Fisiologia & Biofísica, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Mariana Gavioli
- Departamento de Fisiologia & Biofísica, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Carlos Henrique Xavier
- Departamento de Ciências Fisiológicas, Instituto de Ciências Biológicas, Universidade Federal de Goiás, Goiânia, Brazil.
| | - Stephen M Oppenheimer
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Silvia Guatimosim
- Departamento de Fisiologia & Biofísica, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Marco Antônio Peliky Fontes
- Departamento de Fisiologia & Biofísica, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.
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Abstract
BACKGROUND Neurogenic heart syndrome represents a phenomenon often encountered in clinical practice after ischemic stroke. Further poststroke cardiovascular complications are possibly related to cardiac autonomic dysregulation. Multiple Trigonometric Regressive Spectral (MTRS) analysis of the heart rate variability (HRV) allows a precise evaluation of cardiovascular modulation under different conditions. OBJECTIVES This research aims to evaluate the impact of the middle cerebral artery (MCA) ischemic stroke on cardiac autonomic function, using the MTRS analysis of HRV, during sympathetic and parasympathetic activation tests. METHODS The authors analyzed HRV parameters in 20 patients who had a right and 20 who had a left MCA ischemic stroke, under rest condition and during autonomic activation tests (deep breathing and standing tests). Data were compared with 20 age-matched and sex-matched healthy controls. RESULTS Patients who had a right MCA ischemic stroke presented a decreased vagal modulation of the heart rate compared with healthy controls and patients who had a left MCA ischemic stroke, in resting state and during autonomic activation tests. Decreased root mean square of the successive differences, pNN50, high frequency, and high-frequency normalized units values (P<0.05) and increased low frequency/high frequency ratio (P<0.05) in resting state and during autonomic activation tests in patients who had a right MCA stroke indicate a sympathetic predominance in the control of the heart rate. The parasympathetic activation test did not change the sympathovagal balance in this group of patients. CONCLUSIONS The autonomic nervous system represents an attractive target for the therapeutic approach. As MCA ischemic stroke, especially in the right hemisphere, seems to cause significant long-lasting autonomic dysregulation, implementing early pharmacological or nonpharmacological intervention for autonomic restoration may improve the outcome of patients who had an ischemic stroke.
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Balch MH, Nimjee SM, Rink C, Hannawi Y. Beyond the Brain: The Systemic Pathophysiological Response to Acute Ischemic Stroke. J Stroke 2020; 22:159-172. [PMID: 32635682 PMCID: PMC7341014 DOI: 10.5853/jos.2019.02978] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 03/17/2020] [Indexed: 12/12/2022] Open
Abstract
Stroke research has traditionally focused on the cerebral processes following ischemic brain injury, where oxygen and glucose deprivation incite prolonged activation of excitatory neurotransmitter receptors, intracellular calcium accumulation, inflammation, reactive oxygen species proliferation, and ultimately neuronal death. A recent growing body of evidence, however, points to far-reaching pathophysiological consequences of acute ischemic stroke. Shortly after stroke onset, peripheral immunodepression in conjunction with hyperstimulation of autonomic and neuroendocrine pathways and motor pathway impairment result in dysfunction of the respiratory, urinary, cardiovascular, gastrointestinal, musculoskeletal, and endocrine systems. These end organ abnormalities play a major role in the morbidity and mortality of acute ischemic stroke. Using a pathophysiology-based approach, this current review discusses the pathophysiological mechanisms following ischemic brain insult that result in end organ dysfunction. By characterizing stroke as a systemic disease, future research must consider bidirectional interactions between the brain and peripheral organs to inform treatment paradigms and develop effective, comprehensive therapeutics for acute ischemic stroke.
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Affiliation(s)
- Maria H.H. Balch
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Department of Biomedical Education and Anatomy, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Shahid M. Nimjee
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Cameron Rink
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Yousef Hannawi
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Correspondence: Yousef Hannawi Department of Neurology, The Ohio State University Wexner Medical Center, Graves Hall, Suite 3172C, 333 West 10th Ave, Columbus, OH 43210, USA Tel: +1-614-685-7234 Fax: +1-614-366-7004 E-mail:
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Méloux A, Béjot Y, Rochette L, Cottin Y, Vergely C. Brain-Heart Interactions During Ischemic Processes: Clinical and Experimental Evidences. Stroke 2019; 51:679-686. [PMID: 31856693 DOI: 10.1161/strokeaha.119.027732] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Alexandre Méloux
- From the Physiopathologie et Epidémiologie Cérébro-Cardiovasculaires (PEC2, EA 7460), Université de Bourgogne-Franche-Comté, Dijon, France (A.M., L.R., C.V.).,Department of Cardiology (A.M., Y.C.), University Hospital of Dijon, France
| | - Yannick Béjot
- Department of Neurology (Y.B.), University Hospital of Dijon, France
| | - Luc Rochette
- From the Physiopathologie et Epidémiologie Cérébro-Cardiovasculaires (PEC2, EA 7460), Université de Bourgogne-Franche-Comté, Dijon, France (A.M., L.R., C.V.)
| | - Yves Cottin
- Department of Cardiology (A.M., Y.C.), University Hospital of Dijon, France
| | - Catherine Vergely
- From the Physiopathologie et Epidémiologie Cérébro-Cardiovasculaires (PEC2, EA 7460), Université de Bourgogne-Franche-Comté, Dijon, France (A.M., L.R., C.V.)
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Lateralization of Insular Ischemic Stroke is Not Associated With Any Stroke Clinical Outcomes: The Athens Stroke Registry. J Stroke Cerebrovasc Dis 2019; 29:104529. [PMID: 31806455 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 11/07/2019] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Controversial evidence suggests that right insular stroke may be associated with worse outcomes compared to the left insular ischemic lesion. OBJECTIVES We investigated whether lateralization of insular stroke is associated with early and late outcome in terms of in-hospital complications, stroke recurrence, cardiovascular events, and death. METHODS Data were prospectively collected from the Athens Stroke Registry. Insular cortex involvement was identified based on brain CT scans or MRI images. Patients were followed up prospectively at 1, 3, 6 months after hospital discharge and yearly thereafter up to 5-years or until death. The assessed outcomes were in-hospital complications, functional outcome assessed by the modified Rankin Scale, stroke recurrence, cardiovascular events, and death. Cox-regression analysis was performed to estimate the cumulative probability of each outcome according to the lateralization of insular strokes. RESULTS Among the 1212 patients, 650 had left insular stroke involvement and 562 had right. New onset of in-hospital atrial fibrillation was similar between right and left insular strokes (11.6% versus 12.9%, P = .484). During the 5-year follow-up sudden death occurred in 21 (3.7%) patients with right insular compared to 30 (4.6%) with left insular stroke (P = .476). There was no difference between left and right insular strokes regarding mortality (adjusted odds ratio [OR]: .92, 95% confidence interval [CI]: .80-1.06), stroke recurrence (4.3% versus 4.9%; adjusted OR: .81 95% CI: .58-1.13), cardiovascular events, and sudden death (adjusted OR: .99, 95% CI: .76-1.29) and on death and dependency (adjusted OR: .88, 95% CI: .75-1.02) during a 5-year follow up. CONCLUSIONS Lateralization of insular ischemic stroke involvement is not associated with stroke outcomes.
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Ibrahim C, Le Foll B, French L. Transcriptomic Characterization of the Human Insular Cortex and Claustrum. Front Neuroanat 2019; 13:94. [PMID: 31827426 PMCID: PMC6890825 DOI: 10.3389/fnana.2019.00094] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 10/31/2019] [Indexed: 12/13/2022] Open
Abstract
The insular cortex has been linked to a multitude of functions. In contrast, the nearby claustrum is a densely connected subcortical region with unclear function. To view the insula-claustrum region from the molecular perspective we analyzed the transcriptomic profile of these areas in six adult and four fetal human brains. We identified marker genes with specific expression and performed transcriptome-wide tests for enrichment of biological processes, molecular functions, and cellular components. In addition, specific insular and claustral expression of genes pertaining to diseases, addiction, and depression was tested. At the anatomical level, we used brain-wide analyses to determine the specificity of our results and to determine the transcriptomic similarity of the insula-claustrum region. We found UCMA to be the most significantly enriched gene in the insular cortex and confirmed specific expression of NR4A2, NTNG2, and LXN in the claustrum. Furthermore, the insula was found to have enriched expression of genes associated with mood disorders, learning, cardiac muscle contraction, oxygen transport, glutamate and dopamine signaling. Specific expression in the claustrum was enriched for genes pertaining to human immunodeficiency virus (HIV), severe intellectual disability, epileptic encephalopathy, intracellular transport, spine development, and macroautophagy. We tested for enrichment of genes related to addiction and depression, but they were generally not highly specific to the insula-claustrum region. Exceptions include high insular expression of genes linked to cocaine abuse and genes associated with ever smoking in the claustrum. Brain-wide, we find that markers of the adult claustrum are most specifically expressed in the fetal and adult insula. Altogether, our results provide a novel molecular perspective on the unique properties of the insula and claustrum.
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Affiliation(s)
- Christine Ibrahim
- Translational Addiction Research Laboratory, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Bernard Le Foll
- Translational Addiction Research Laboratory, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
- Addictions Division, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Division of Brain and Therapeutics, Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Leon French
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Division of Brain and Therapeutics, Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Krembil Centre for Neuroinformatics, Centre for Addiction and Mental Health, Toronto, ON, Canada
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Marzolini S, Robertson AD, Oh P, Goodman JM, Corbett D, Du X, MacIntosh BJ. Aerobic Training and Mobilization Early Post-stroke: Cautions and Considerations. Front Neurol 2019; 10:1187. [PMID: 31803129 PMCID: PMC6872678 DOI: 10.3389/fneur.2019.01187] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 10/25/2019] [Indexed: 12/14/2022] Open
Abstract
Knowledge gaps exist in how we implement aerobic exercise programs during the early phases post-stroke. Therefore, the objective of this review was to provide evidence-based guidelines for pre-participation screening, mobilization, and aerobic exercise training in the hyper-acute and acute phases post-stroke. In reviewing the literature to determine safe timelines of when to initiate exercise and mobilization we considered the following factors: arterial blood pressure dysregulation, cardiac complications, blood-brain barrier disruption, hemorrhagic stroke transformation, and ischemic penumbra viability. These stroke-related impairments could intensify with inappropriate mobilization/aerobic exercise, hence we deemed the integrity of cerebral autoregulation to be an essential physiological consideration to protect the brain when progressing exercise intensity. Pre-participation screening criteria are proposed and countermeasures to protect the brain from potentially adverse circulatory effects before, during, and following mobilization/exercise sessions are introduced. For example, prolonged periods of standing and static postures before and after mobilization/aerobic exercise may elicit blood pooling and/or trigger coagulation cascades and/or cerebral hypoperfusion. Countermeasures such as avoiding prolonged standing or incorporating periodic lower limb movement to activate the venous muscle pump could counteract blood pooling after an exercise session, minimize activation of the coagulation cascade, and mitigate potential cerebral hypoperfusion. We discuss patient safety in light of the complex nature of stroke presentations (i.e., type, severity, and etiology), medical history, comorbidities such as diabetes, cardiac manifestations, medications, and complications such as anemia and dehydration. The guidelines are easily incorporated into the care model, are low-risk, and use minimal resources. These and other strategies represent opportunities for improving the safety of the activity regimen offered to those in the early phases post-stroke. The timeline for initiating and progressing exercise/mobilization parameters are contingent on recovery stages both from neurobiological and cardiovascular perspectives, which to this point have not been specifically considered in practice. This review includes tailored exercise and mobilization prescription strategies and precautions that are not resource intensive and prioritize safety in stroke recovery.
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Affiliation(s)
- Susan Marzolini
- KITE, Toronto Rehab-University Health Network, Toronto, ON, Canada
- Department of Exercise Sciences, Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
- Canadian Partnership for Stroke Recovery, Toronto, ON, Canada
| | - Andrew D. Robertson
- Schlegel-University of Waterloo Research Institute for Aging, University of Waterloo, Waterloo, ON, Canada
- Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada
| | - Paul Oh
- KITE, Toronto Rehab-University Health Network, Toronto, ON, Canada
- Department of Exercise Sciences, Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
- Canadian Partnership for Stroke Recovery, Toronto, ON, Canada
| | - Jack M. Goodman
- KITE, Toronto Rehab-University Health Network, Toronto, ON, Canada
- Department of Exercise Sciences, Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Dale Corbett
- Canadian Partnership for Stroke Recovery, Toronto, ON, Canada
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Xiaowei Du
- KITE, Toronto Rehab-University Health Network, Toronto, ON, Canada
- School of Kinesiology and Health Studies, Queen's University, Kingston, ON, Canada
| | - Bradley J. MacIntosh
- Canadian Partnership for Stroke Recovery, Toronto, ON, Canada
- Sunnybrook Health Sciences Center, Toronto, ON, Canada
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Song X, Roy B, Fonarow GC, Woo MA, Kumar R. Brain structural changes associated with aberrant functional responses to the Valsalva maneuver in heart failure. J Neurosci Res 2019; 96:1610-1622. [PMID: 30113721 DOI: 10.1002/jnr.24264] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 04/19/2018] [Accepted: 05/15/2018] [Indexed: 12/11/2022]
Abstract
Heart failure (HF) patients show inability to regulate autonomic functions in response to autonomic challenges. The autonomic deficits may stem from brain tissue injury in central autonomic regulatory areas, resulting from ischemic and hypoxic processes accompanying the condition. However, the direct evaluation of correlations between brain structural injury and functional timing and magnitude of neural signal patterns within affected areas, which may lead to impaired autonomic outflow, is unclear. In this study, we evaluate neural responses to the Valsalva maneuver with blood oxygen level-dependent functional magnetic resonance imaging in 29 HF patients and 35 control subjects and brain structural changes using diffusion tensor imaging-based mean diffusivity in a subsample of 19 HF and 24 control subjects. HF showed decreased neural activation in multiple autonomic and motor control areas, including cerebellum cortices, vermis, left insular, left putamen, and bilateral postcentral gyrus. Structural brain changes emerged in similar autonomic, as well as cognitive and mood regulation areas. Functional MRI responses in cerebellum and insula in HF subjects are delayed or decreased in magnitude to the challenge. The impaired functional responses of insular and cerebellar sites are correlated with the severity of tissue changes. These results indicate that the functions of insular and cerebellar regions, sites that are involved in autonomic regulation, are compromised, and that autonomic deficits in these areas have brain structural basis for impaired functions. Our study enhanced our understanding of brain structural and functional alterations underlying impaired autonomic regulations in HF subjects.
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Affiliation(s)
- Xiaopeng Song
- Department of Anesthesiology, University of California at Los Angeles, Los Angeles, California, USA
| | - Bhaswati Roy
- UCLA School of Nursing, University of California at Los Angeles, Los Angeles, California, USA
| | - Gregg C Fonarow
- Department of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | - Mary A Woo
- UCLA School of Nursing, University of California at Los Angeles, Los Angeles, California, USA
| | - Rajesh Kumar
- Department of Anesthesiology, University of California at Los Angeles, Los Angeles, California, USA.,Department of Radiological Sciences, University of California at Los Angeles, Los Angeles, California, USA.,Department of Bioengineering, University of California at Los Angeles, Los Angeles, California, USA.,The Brain Research Institute, University of California at Los Angeles, Los Angeles, California, USA
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Lin XQ, Zheng LR. Myocardial ischemic changes of electrocardiogram in intracerebral hemorrhage: A case report and review of literature. World J Clin Cases 2019. [DOI: 10.12998/wjcc.v7.i21.3586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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Lin XQ, Zheng LR. Myocardial ischemic changes of electrocardiogram in intracerebral hemorrhage: A case report and review of literature. World J Clin Cases 2019; 7:3603-3614. [PMID: 31750344 PMCID: PMC6854395 DOI: 10.12998/wjcc.v7.i21.3603] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 09/22/2019] [Accepted: 10/05/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Cardiac injury may occur after acute pathology of central nervous system (CNS) without any evidence of primary cardiac diseases. The resulting structural and/or functional changes are called cerebrocardiac syndrome (CCS). The great majority of studies have been performed in patients with subarachnoid hemorrhage (SAH), while CCS data after intracerebral hemorrhage (ICH) are rare. It may cause diagnostic and therapeutic pitfalls for the clinician due to a lack of specific clinical manifestations and diagnostic methods. Understanding the underlying pathophysiological and molecular mechanism(s) following cerebrovascular incidents will help to implement prevention and treatment strategies to improve the prognosis.
CASE SUMMARY A 37-year-old man with a history of hypertension presented to our department on an emergency basis because of a sudden dizziness and left limb weakness. Cerebral computed tomography (CT) suggested ICH in the occipital and parietal lobes, and the chosen emergency treatment was hematoma evacuation. Left ventricular (LV) dysfunction occurred after the next 48 h and the electrocardiogram (ECG) showed non-ST elevation myocardial infarction. CCS was suspected first in the context of ICH due to the negative result of the coronary CT angiogram.
CONCLUSION Misinterpretation of ischemic-like ECGs may lead to unnecessary or hazardous interventions and cause undue delay of rehabilitation after stroke. Our objective is to highlight the clinical implications of CCS and we hope the differential diagnoses will be considered in patients with acute CNS diseases.
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Affiliation(s)
- Xue-Qi Lin
- Department of Cardiovascular, The First Affiliated Hospital of Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Liang-Rong Zheng
- Department of Cardiovascular, The First Affiliated Hospital of Zhejiang University, Hangzhou 310003, Zhejiang Province, China
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Constantinescu V, Arsenescu-Georgescu C, Matei D, Moscalu M, Corciova C, Cuciureanu D. Heart rate variability analysis and cardiac dysautonomia in ischemic stroke patients. Clin Neurol Neurosurg 2019; 186:105528. [DOI: 10.1016/j.clineuro.2019.105528] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 08/02/2019] [Accepted: 09/15/2019] [Indexed: 11/27/2022]
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40
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Romano IJ, Lippolis A, D'Anna M, Gentile F. Cardiac Arrhythmias and Acute Cerebrovascular Events: A Case of QT Prolongation and Torsades de Pointes Early After Right Insular Stroke. J Stroke Cerebrovasc Dis 2019; 28:104308. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.104308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 06/17/2019] [Accepted: 07/21/2019] [Indexed: 10/26/2022] Open
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Balint B, Jaremek V, Thorburn V, Whitehead SN, Sposato LA. Left atrial microvascular endothelial dysfunction, myocardial inflammation and fibrosis after selective insular cortex ischemic stroke. Int J Cardiol 2019; 292:148-155. [DOI: 10.1016/j.ijcard.2019.06.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 05/15/2019] [Accepted: 06/01/2019] [Indexed: 02/06/2023]
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Meloux A, Rigal E, Rochette L, Cottin Y, Bejot Y, Vergely C. Ischemic Stroke Increases Heart Vulnerability to Ischemia-Reperfusion and Alters Myocardial Cardioprotective Pathways. Stroke 2019; 49:2752-2760. [PMID: 30355197 DOI: 10.1161/strokeaha.118.022207] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background and Purpose- For years, the relationship between cardiac and neurological ischemic events has been limited to overlapping pathophysiological mechanisms and common risk factors. However, acute stroke may induce dramatic changes in cardiovascular function. The aim of this study was to evaluate how prior cerebrovascular lesions affect myocardial function and signaling in vivo and ex vivo and how they influence cardiac vulnerability to ischemia-reperfusion injury. Methods- Cerebral embolization was performed in adult Wistar male rats through the injection of microspheres into the left or right internal carotid artery. Stroke lesions were evaluated by microsphere counting, tissue staining, and assessment of neurological deficit 2 hours, 24 hours, and 7 days after surgery. Cardiac function was evaluated in vivo by echocardiography and ex vivo in isolated perfused hearts. Heart vulnerability to ischemia-reperfusion injury was investigated ex vivo at different times post-embolization and with varying degrees of myocardial ischemia. Left ventricles (LVs) were analyzed with Western blotting and quantitatve real-time polymerase chain reaction. Results- Our stroke model produced large cerebral infarcts with severe neurological deficit. Cardiac contractile dysfunction was observed with an early but persistent reduction of LV fractional shortening in vivo and of LV developed pressure ex vivo. Moreover, after 20 or 30 minutes of global cardiac ischemia, recovery of contractile function was poorer with impaired LV developed pressure and relaxation during reperfusion in both stroke groups. Following stroke, circulating levels of catecholamines and GDF15 (growth differentiation factor 15) increased. Cerebral embolization altered nitro-oxidative stress signaling and impaired the myocardial expression of ADRB1 (adrenoceptor β1) and cardioprotective Survivor Activating Factor Enhancement signaling pathways. Conclusions- Our findings indicate that stroke not only impairs cardiac contractility but also worsens myocardial vulnerability to ischemia. The underlying molecular mechanisms of stroke-induced myocardial alterations after cerebral embolization remain to be established, insofar as they may involve the sympathetic nervous system and nitro-oxidative stress.
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Affiliation(s)
- Alexandre Meloux
- From the Equipe d'Accueil (EA 7460), Physiopathologie et Epidémiologie Cérébro-Cardiovasculaires (PEC2), Université de Bourgogne-Franche-Comté, UFR des Sciences de Santé, 7 Bd Jeanne d'Arc, 21000 Dijon, France (A.M., E.R., L.R., Y.C., Y.B., C.V.).,Department of Cardiology (A.M., Y.C.), University Hospital of Dijon, France
| | - Eve Rigal
- From the Equipe d'Accueil (EA 7460), Physiopathologie et Epidémiologie Cérébro-Cardiovasculaires (PEC2), Université de Bourgogne-Franche-Comté, UFR des Sciences de Santé, 7 Bd Jeanne d'Arc, 21000 Dijon, France (A.M., E.R., L.R., Y.C., Y.B., C.V.)
| | - Luc Rochette
- From the Equipe d'Accueil (EA 7460), Physiopathologie et Epidémiologie Cérébro-Cardiovasculaires (PEC2), Université de Bourgogne-Franche-Comté, UFR des Sciences de Santé, 7 Bd Jeanne d'Arc, 21000 Dijon, France (A.M., E.R., L.R., Y.C., Y.B., C.V.)
| | - Yves Cottin
- From the Equipe d'Accueil (EA 7460), Physiopathologie et Epidémiologie Cérébro-Cardiovasculaires (PEC2), Université de Bourgogne-Franche-Comté, UFR des Sciences de Santé, 7 Bd Jeanne d'Arc, 21000 Dijon, France (A.M., E.R., L.R., Y.C., Y.B., C.V.).,Department of Cardiology (A.M., Y.C.), University Hospital of Dijon, France
| | - Yannick Bejot
- From the Equipe d'Accueil (EA 7460), Physiopathologie et Epidémiologie Cérébro-Cardiovasculaires (PEC2), Université de Bourgogne-Franche-Comté, UFR des Sciences de Santé, 7 Bd Jeanne d'Arc, 21000 Dijon, France (A.M., E.R., L.R., Y.C., Y.B., C.V.).,Department of Neurology (Y.B.), University Hospital of Dijon, France
| | - Catherine Vergely
- From the Equipe d'Accueil (EA 7460), Physiopathologie et Epidémiologie Cérébro-Cardiovasculaires (PEC2), Université de Bourgogne-Franche-Comté, UFR des Sciences de Santé, 7 Bd Jeanne d'Arc, 21000 Dijon, France (A.M., E.R., L.R., Y.C., Y.B., C.V.)
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Insular resection may lead to autonomic function changes. Epilepsy Behav 2019; 97:260-264. [PMID: 31254846 PMCID: PMC6916254 DOI: 10.1016/j.yebeh.2019.04.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 04/16/2019] [Accepted: 04/19/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The aim of this study was to determine if insular damage is associated with markers of autonomic dysfunction. METHODS We studied patients who underwent temporal lobe and/or insular resections for epilepsy surgery between April 2010 and June 2015 at University Hospitals Cleveland Medical Center (UHCMC). Presurgical T1-weighted MPRAGE, standard T1, T2 and FLAIR sequences were compared with postsurgical MRI by a neuroradiologist and classified as type 0 (no involvement of insula), type 1 (minimal involvement of insular margin), type 2 (insular involvement <25%), and type 3 (insular involvement ≥25%). Analysis of heart rate variability (HRV) was carried out in pre- and postoperative video-electroencephalography (vEEG) recording. Time-domain parameters were calculated: (mean of the RR intervals (MNN), root mean square difference of successive RR intervals (RMSSD), standard deviation of the RR intervals (SDNN), and coefficient of variation (CV)). In addition, frequency-domain parameters were calculated: low frequency (LF), high frequency (HF), and low frequency/high frequency (LF/HF). RESULTS Twenty-one patients (14 females) with mean age of 36.2 ± 14.4 years (30; 22-75) were studied. Insular involvement was classified as type 0 (4 patients [19%]), type 1 (9 [43%]), type 2 (7 [33%]), and type 3 (1 [5%]). Significant decrease in RMSSD (p = 0.025) and CV (p = 0.008) was seen in insular damage types 2 and 3 compared with no or minimal insular involvement (types 0 and 1). Right-sided resections were associated with increase in LF power (p = 0.010) and the LF/HF ratio (p = 0.017). CONCLUSIONS This study indicates that insular resection may lead to autonomic function changes.
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Raghu ALB, Parker T, van Wyk A, Green AL. Insula stroke: the weird and the worrisome. Postgrad Med J 2019; 95:497-504. [PMID: 31296791 DOI: 10.1136/postgradmedj-2019-136732] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/10/2019] [Accepted: 06/23/2019] [Indexed: 01/10/2023]
Abstract
Infarction of the insula is a common scenario with large tissue-volume strokes in the middle cerebral artery territory. Considered to be part of the central autonomic network, infarction of this region is associated with autonomic disturbances, in particular cardiovascular dysregulation. Risk of aspiration following stroke is also associated with involvement of the insula, consistent with its purported participation in complex functions of the mouth and pharynx. Strokes restricted to the insula are rare and present with a broad range of symptoms that offer a window of insight into the diverse functionality of the insular cortex. Chemosensory, autonomic, vestibular, auditory, somatosensory, language and oropharyngeal functional deficits are all recognised, among others. Long-term sequelae are unknown but profound symptoms, such as hemiparesis, are usually transient. Understanding the patterns of dysfunction highlighted provides the basis for future strategies to optimise stroke management on the discovery of insula involvement.
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Affiliation(s)
| | - Tariq Parker
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - André van Wyk
- Acute Stroke Unit, Royal Berkshire Hospital, Reading, UK
| | - Alexander Laurence Green
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.,Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Crevier-Sorbo G, Atkinson J, Di Genova T, Puligandla P, Dudley RWR. Hydrocephalus-induced neurogenic stunned myocardium and cardiac arrest in a child: completely reversed with CSF diversion. J Neurosurg Pediatr 2019; 24:35-40. [PMID: 31003226 DOI: 10.3171/2019.2.peds18711] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 02/28/2019] [Indexed: 01/11/2023]
Abstract
Neurogenic stunned myocardium (NSM) is a potentially fatal cause of sudden cardiogenic dysfunction due to an acute neurological event, most commonly aneurysmal subarachnoid hemorrhage in adults. Only two pediatric cases of hydrocephalus-induced NSM have been reported. Here the authors report a third case in a 14-year-old boy who presented with severe headache, decreased level of consciousness, and shock in the context of acute hydrocephalus secondary to fourth ventricular outlet obstruction 3 years after standard-risk medulloblastoma treatment. He was initially stabilized with the insertion of an external ventricular drain and vasopressor treatment. He had a profoundly reduced cardiac contractility and became asystolic for 1 minute, requiring cardiopulmonary resuscitation when vasopressors were inadvertently discontinued. Over 1 week, his ventricles decreased in size and his cardiac function returned to normal. All other causes of heart failure were ruled out, and his impressive response to CSF diversion clarified the diagnosis of NSM secondary to hydrocephalus. He was unable to be weaned from his drain during his time in the hospital, so he underwent an endoscopic third ventriculostomy and has remained well with normal cardiac function at more than 6 months' follow-up. This case highlights the importance of prompt CSF diversion and cardiac support for acute hydrocephalus presenting with heart failure in the pediatric population.
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Tobaldini E, Proserpio P, Oppo V, Figorilli M, Fiorelli EM, Manconi M, Agostoni EC, Nobili L, Montano N, Horvath T, Bassetti CL. Cardiac autonomic dynamics during sleep are lost in patients with TIA and stroke. J Sleep Res 2019; 29:e12878. [PMID: 31192512 DOI: 10.1111/jsr.12878] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 04/26/2019] [Accepted: 04/27/2019] [Indexed: 01/28/2023]
Abstract
Ischaemic stroke is accompanied by important alterations of cardiac autonomic control, which have an impact on stroke outcome. In sleep, cardiac autonomic control oscillates with a predominant sympathetic modulation during REM sleep. We aimed to assess cardiac autonomic control in different sleep stages in patients with ischaemic stroke. Forty-five patients enrolled in the prospective, multicentre SAS-CARE study but without significant sleep-disordered breathing (apnea-hypopnea index < 15/hr) and without atrial fibrillation were included in this analysis. The mean age was 56 years, 68% were male, 76% had a stroke (n = 34, mean National Institutes of Health Stroke Scale [NIHSS] score of 5, 11 involving the insula) and 24% (n = 11) had a transitory ischaemic attack. Cardiac autonomic control was evaluated using three different tools (spectral, symbolic and entropy analysis) according to sleep stages on short segments of 250 beats in all patients. Polysomnographic studies were performed within 7 days and 3 months after the ischaemic event. No significant differences in cardiac autonomic control between sleep stages were observed in the acute phase and after 3 months. Predominant vagal modulation and decreased sympathetic modulation were observed across all sleep stages in ischaemic stroke involving the insula. Patients with ischaemic stroke and transitory ischaemic attack present a loss of cardiac autonomic dynamics during sleep in the first 3 months after the ischaemic event. This change could represent an adaptive phenomenon, protecting the cardiovascular system from the instabilities of autonomic control, or a risk factor for stroke, which precedes the ischaemic event.
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Affiliation(s)
- Eleonora Tobaldini
- Department of Internal Medicine, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | | | - Valentina Oppo
- Department of Neuroscience, Niguarda Hospital, Milan, Italy
| | | | - Elisa M Fiorelli
- Department of Internal Medicine, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Mauro Manconi
- Sleep and Epilepsy Center, Neurocenter of Southern Switzerland, Civic Hospital of Lugano, Lugano, Switzerland.,Department of Neurology, Inselspital, University Hospital, Bern, Switzerland
| | | | - Lino Nobili
- Department of Neuroscience, Niguarda Hospital, Milan, Italy.,Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy
| | - Nicola Montano
- Department of Internal Medicine, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Thomas Horvath
- Department of Neurology, Inselspital, University Hospital, Bern, Switzerland
| | - Claudio L Bassetti
- Department of Neurology, Inselspital, University Hospital, Bern, Switzerland
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Tobaldini E, Sacco RM, Serafino S, Tassi M, Gallone G, Solbiati M, Costantino G, Montano N, Torgano G. Cardiac Autonomic Derangement is Associated with Worse Neurological Outcome in the Very Early Phases of Ischemic Stroke. J Clin Med 2019; 8:E852. [PMID: 31208012 PMCID: PMC6616397 DOI: 10.3390/jcm8060852] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 06/09/2019] [Accepted: 06/11/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Acute ischemic stroke (AIS) is associated with autonomic dysfunction. We evaluated the prognostic value of heart rate variability (HRV) and the role of stroke localization and reperfusion treatment (RT) on autonomic control. METHODS Patients with AIS and sinus rhythm were enrolled in the emergency department. Autonomic parameters were recorded at the onset and after a potential RT. Neurological deficit was assessed using the National Institute of Health Stroke Scale (NIHSS) at the onset and residual disability with modified Rankin Scale (mRS) at 3 months. Two analyses were used to assess HRV. Low frequency (LF) and high frequency (HF) are, respectively, markers of sympathetic and respiratory vagal modulation in spectral analysis. Symbolic analysis provides pattern with no variation (0V%) as an index of sympathetic modulation and pattern with two like variations (2LV%) and pattern with two unlike variations (2UV%) as markers of vagal modulation. RESULTS We enrolled 41 patients. Twenty-seven underwent RT. A prevalent parasympathetic modulation was found in patients with NIHSS ≥14. The group with mRS 3-6 exhibited a higher 2UV% and lower 0V%. Right-sided strokes were associated with a higher respiratory vagal control. RT had no effects on HRV parameters. CONCLUSIONS In the very early phases of AIS, a decreased 0V% and an increased 2UV% may reflect a loss of sympathetic oscillation, predicting a poorer 3 month-outcome.
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Affiliation(s)
- Eleonora Tobaldini
- Department of Internal Medicine , Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy.
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy.
| | - Roberto M Sacco
- Department of Internal Medicine , Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy.
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy.
| | - Serena Serafino
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCSS Ca' Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy.
| | - Michele Tassi
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy.
| | - Gianluca Gallone
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCSS Ca' Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy.
| | - Monica Solbiati
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy.
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCSS Ca' Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy.
| | - Giorgio Costantino
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy.
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCSS Ca' Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy.
| | - Nicola Montano
- Department of Internal Medicine , Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy.
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy.
| | - Giuseppe Torgano
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCSS Ca' Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy.
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Silva AR, Magalhães R, Arantes C, Moreira PS, Rodrigues M, Marques P, Marques J, Sousa N, Pereira VH. Brain functional connectivity is altered in patients with Takotsubo Syndrome. Sci Rep 2019; 9:4187. [PMID: 30862828 PMCID: PMC6414524 DOI: 10.1038/s41598-019-40695-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 02/21/2019] [Indexed: 12/28/2022] Open
Abstract
Takotsubo syndrome (TTS) is an acute, reversible cardiomyopathy. The central autonomic nervous system (ANS) is believed to play a role in this disease. The aim of the present study was to investigate the patterns of brain functional connectivity in a sample of patients who had experienced a previous episode of TTS. Brain functional connectivity, both at rest and in response to the stressful stimulus of topical cold stimulation, was explored using functional magnetic resonance imaging (fMRI), network-based statistics (NBS) and graph theory analysis (GTA) in a population consisting of eight patients with a previous episode of TTS and eight sex- and age-matched controls. At rest, a network characterized by increased connectivity in the TTS group compared to controls and comprising elements of the central ANS was identified. GTA revealed increased local efficiency, clustering and strength in regions of the bilateral hippocampus in subjects with a previous episode of TTS. When stressed by local exposure to cold, the TTS group differed significantly from both a pre-stress baseline interval and from the control group, showing increased connectivity in a network that included the left amygdala and the right insula. Based on the results, patients with TTS display a reorganization of cortical and subcortical networks, including areas associated with the emotional response and autonomic regulation. The findings tend to support the hypothesis that a deregulation of autonomic control at the central level plays a significant role in this syndrome.
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Affiliation(s)
- Ana Rita Silva
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's - PT Government Associate Laboratory, Braga, Portugal
| | - Ricardo Magalhães
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's - PT Government Associate Laboratory, Braga, Portugal
- Clinical Academic Center (2CA - Braga), Braga, Portugal
| | - Carina Arantes
- Cardiology Department, Hospital of Braga, Braga, Portugal
| | - Pedro Silva Moreira
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's - PT Government Associate Laboratory, Braga, Portugal
- Algoritmi Centre, University of Minho, Braga, Portugal
| | - Mariana Rodrigues
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's - PT Government Associate Laboratory, Braga, Portugal
- Clinical Academic Center (2CA - Braga), Braga, Portugal
| | - Paulo Marques
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's - PT Government Associate Laboratory, Braga, Portugal
- Clinical Academic Center (2CA - Braga), Braga, Portugal
| | - Jorge Marques
- Cardiology Department, Hospital of Braga, Braga, Portugal
| | - Nuno Sousa
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's - PT Government Associate Laboratory, Braga, Portugal
- Clinical Academic Center (2CA - Braga), Braga, Portugal
| | - Vitor Hugo Pereira
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.
- ICVS/3B's - PT Government Associate Laboratory, Braga, Portugal.
- Clinical Academic Center (2CA - Braga), Braga, Portugal.
- Cardiology Department, Hospital of Braga, Braga, Portugal.
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Jobst BC, Gonzalez-Martinez J, Isnard J, Kahane P, Lacuey N, Lahtoo SD, Nguyen DK, Wu C, Lado F. The Insula and Its Epilepsies. Epilepsy Curr 2019; 19:11-21. [PMID: 30838920 PMCID: PMC6610377 DOI: 10.1177/1535759718822847] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Insular seizures are great mimickers of seizures originating elsewhere in the
brain. The insula is a highly connected brain structure. Seizures may only
become clinically evident after ictal activity propagates out of the insula with
semiology that reflects the propagation pattern. Insular seizures with
perisylvian spread, for example, manifest first as throat constriction, followed
next by perioral and hemisensory symptoms, and then by unilateral motor
symptoms. On the other hand, insular seizures may spread instead to the temporal
and frontal lobes and present like seizures originating from these regions. Due
to the location of the insula deep in the brain, interictal and ictal scalp
electroencephalogram (EEG) changes can be variable and misleading. Magnetic
resonance imaging, magnetic resonance spectroscopy, magnetoencephalography,
positron emission tomography, and single-photon computed tomography imaging may
assist in establishing a diagnosis of insular epilepsy. Intracranial EEG
recordings from within the insula, using stereo-EEG or depth electrode
techniques, can prove insular seizure origin. Seizure onset, most commonly seen
as low-voltage, fast gamma activity, however, can be highly localized and easily
missed if the insula is only sparsely sampled. Moreover, seizure spread to the
contralateral insula and other brain regions may occur rapidly. Extensive
sampling of the insula with multiple electrode trajectories is necessary to
avoid these pitfalls. Understanding the functional organization of the insula is
helpful when interpreting the semiology produced by insular seizures. Electrical
stimulation mapping around the central sulcus of the insula results in
paresthesias, while stimulation of the posterior insula typically produces
painful sensations. Visceral sensations are the next most common result of
insular stimulation. Treatment of insular epilepsy is evolving, but poses
challenges. Surgical resections of the insula are effective but risk significant
morbidity if not carefully planned. Neurostimulation is an emerging option for
treatment, especially for seizures with onset in the posterior insula. The close
association of the insula with marked autonomic changes has led to interest in
the role of the insula in sudden unexpected death in epilepsy and warrants
additional study with larger patient cohorts.
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Affiliation(s)
| | | | - Jean Isnard
- 3 Hospices Civils de Lyon, Hospital for Neurology and Neurosurgery, Lyon, France
| | | | - Nuria Lacuey
- 5 University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Samden D Lahtoo
- 5 University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | | | - Chengyuan Wu
- 7 Thomas Jefferson University, Philadelphia, PA, USA
| | - Fred Lado
- 8 Northwell Health, Great Neck, NY, USA
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50
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Liesirova K, Abela E, Pilgrim T, Bickel L, Meinel T, Meisterernst J, Rajeev V, Sarikaya H, Heldner MR, Dobrocky T, Siqueira E, El-Koussy M, Fischer U, Gralla J, Arnold M, Mattle HP, Hsieh K, Jung S. Baseline Troponin T level in stroke and its association with stress cardiomyopathy. PLoS One 2018; 13:e0209764. [PMID: 30596715 PMCID: PMC6312325 DOI: 10.1371/journal.pone.0209764] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 12/11/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Differential diagnosis of elevated high sensitive Troponin T (hsTnT) in acute ischemic stroke includes myocardial infarction (MI) and neurogenic stunned myocardium (NSM). The aim of this study was to identify factors associated with baseline hsTnT levels and MI or NSM in acute ischemic stroke. METHODS We studied 204 consecutive patients of the prospective acquired Bern Stroke Database with acute ischemic stroke diagnosed by brain MR. All patient histories and cardiac examinations were reviewed retrospectively. Volumetry of lesions on diffusion and perfusion weighted brain imaging (circular singular value decomposition, Tmax >6sec) was performed. Voxel based analysis was performed to identify brain areas associated with hsTnT elevation. Linear regression analysis was used to identify predictors of baseline hsTnT levels and myocardial infarction. RESULTS Elevated hsTnT was observed in 58 of the 204 patients (28.4%). The mean age was 68.3 years in the normal hsTnT group and 69.7 years in the elevated hsTnT group. Creatinine (p<0.001, OR 6.735, 95% CI 58.734-107.423), baseline NIHSS score (p = 0.029, OR 2.207, 95% CI 0.675-12.096), ST segment depression (p = 0.025, OR 2.259, 95% CI 2.419-35.838), and negative T waves in baseline ECG (p = 0.002, OR 3.209, 95% CI 13.007-54.564) were associated with hsTnT elevation, while infarct location and size were not. Coronary angiography was performed in 30 of the 204 patients (14.7%) and myocardial infarction was diagnosed in 7 of them (23.3%). Predictive factors for myocardial infarction could not be identified. CONCLUSION Elevated baseline baseline hsTnT was associated with NIHSS, creatinine, ST segment depression and inverted T waves, but not with stroke location or size. None of the factors was helpful to differentiate MI and NSM. Therefore, ancillary investigations such as coronary angiography, cardiac MRI or both may be needed to solve the differential diagnosis.
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Affiliation(s)
- Kai Liesirova
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Eugenio Abela
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Laura Bickel
- University Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern, Switzerland
| | - Thomas Meinel
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Julia Meisterernst
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Verma Rajeev
- University Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern, Switzerland
| | - Hakan Sarikaya
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mirjam R. Heldner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tomas Dobrocky
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Erick Siqueira
- University Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern, Switzerland
| | - Marwan El-Koussy
- University Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jan Gralla
- University Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Heinrich P. Mattle
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Kety Hsieh
- University Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- * E-mail:
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