Vistasp Daruwalla

Association of chronic kidney disease with abnormal cardiac mechanics and adverse outcomes in patients with heart failure and preserved ejection fraction.

Chronic kidney disease (CKD) is associated with worse outcomes in heart failure with preserved ejection fraction (HFpEF). Whether this association is due the effect of CKD on intrinsic abnormalities in cardiac function is unknown. We hypothesized that CKD is independently associated with worse cardiac mechanics in HFpEF.

Prognostic Utility and Clinical Significance of Cardiac Mechanics in Heart Failure With Preserved Ejection Fraction: Importance of Left Atrial Strain.

Background—Left atrial (LA) enlargement is associated with adverse events in heart failure with preserved ejection fraction (HFpEF). However, the role of LA mechanics (ie, LA strain measures) in HFpEF has not been well studied. We hypothesized that in HFpEF, reduced (worse) LA strain is a key pathophysiologic abnormality and is a stronger correlate of adverse events than left ventricular or right ventricular longitudinal strain. Methods and Results—We evaluated baseline LA function in 308 patients with HFpEF who were followed up longitudinally for adverse outcomes. All patients underwent speckle-tracking echocardiography for measurement of left ventricular longitudinal strain, right ventricular free wall strain, and LA booster, conduit, and reservoir strains. The clinical and prognostic significance of left ventricular, right ventricular, and LA strain measures was assessed by regression analyses. The mean age was 65±13 years, 64% were women, 26% had atrial fibrillation, and LA enlargement was present in the majority of patients (67%). Decreased LA reservoir strain was associated with increased pulmonary vascular resistance (P<0.0001) and decreased peak oxygen consumption (P=0.0001). Of the left ventricular, right ventricular, and LA strain measures, LA reservoir strain was the strongest correlate of adverse events and was independently associated with the composite outcome of cardiovascular hospitalization or death (adjusted hazard ratio per 1-SD decrease in LA strain, 1.54; 95% CI, 1.15–2.07; P=0.006). Conclusions—Abnormal indices of LA mechanics (particularly LA reservoir strain) are powerful clinical and prognostic factors in HFpEF. Unloading the LA and augmentation of LA function may be important future therapeutic targets in HFpEF. Registration Information—URL: http://www.clinicaltrials.gov. Unique identifier: NCT01030991.

Diagnostic Yield of Pelvic Magnetic Resonance Venography in Patients With Cryptogenic Stroke and Patent Foramen Ovale

Background and Purpose— Paradoxical embolization is frequently posited as a mechanism of ischemic stroke in patients with patent foramen ovale. Several studies have suggested that the deep lower extremity and pelvic veins might be an embolic source in cryptogenic stroke (CS) patients with patent foramen ovale. Methods— Consecutive adult patients with ischemic stroke or transient ischemic attack and a patent foramen ovale who underwent pelvic magnetic resonance venography as part of an inpatient diagnostic evaluation were included in this single-center retrospective observational study to determine pelvic and lower extremity (LE) deep venous thrombosis (DVT) prevalence in CS versus non-CS stroke subtypes. Results— Of 131 patients who met inclusion criteria, 126 (96.2%) also had LE duplex ultrasound data. DVT prevalence overall was 7.6% (95% confidence interval, 4.1–13.6), pelvic DVT 1.5% (95% confidence interval, 0.1–5.8), and LE DVT 7.1% (95% confidence interval, 3.6–13.2). One patient with a pelvic DVT also had a LE DVT. Comparing patients with CS (n=98) with non-CS subtypes (n=33), there was no significant difference in the prevalence of pelvic DVT (2.1% versus 0%, P=1), LE DVT (6.2% versus 10.3%, P=0.43), or any DVT (7.2% versus 9.1%, P=0.71). Conclusions— Among patients with ischemic stroke/transient ischemic attack and patent foramen ovale, the majority of detected DVTs were in LE veins rather than the pelvic veins and did not differ by stroke subtype. The routine inclusion of pelvic magnetic resonance venography in the diagnostic evaluation of CS warrants further prospective investigation.

Extranodal Rosai-Dorfman Disease Involving the Left Atrium: Cardiac MRI, CT, and PET Scan Findings

Rosai-Dorfman disease (RDD) is a rare entity that usually involves the lymph nodes but extranodal involvements have been seen in numerous cases, although RDD with cardiovascular involvement is extremely rare. We describe a case of a young male who presented with intermittent palpitations and was found to have a left atrium mass. Our case not only emphasizes the rarity of the above lesion but also highlights the importance of modern-day imaging like computed tomography, Cardiac Magnetic Resonance Imaging (CMRI), and PET scan in characterizing such nonspecific lesions and directing appropriate line of treatment. RDD should be considered as one of the differentials even for isolated cardiac lesions.

Large basilar perforator pseudoaneurysm: A case report

Basilar perforator aneurysms are rare and a communication between a basilar perforator and a separate pseudoaneurysm cavity is extremely rare. We describe a case presenting with high grade subarachnoid hemorrhage which on further investigation delineated a 2–3 mm dissecting basilar perforator aneurysm communicating superiorly into a contained 6 mm pseudoaneurysm cavity. This case illustrates an unusual neurovascular pathology with low potential for successful endovascular treatment such as coil embolization or intracranial flow diverter stenting. Conservative medical management remains the main stay of treatment for such poor surgical candidates.

Phencyclidine Induced Oculogyric Crisis Responding Well to Conventional Treatment.

Background. Oculogyric crisis is a form of acute dystonic reaction characterized by involuntary upward deviation of eye ball. Its causes are broad with antipsychotics and antiemetics as the most common causes. Case Presentation. A 25-year-old man with the past medical history of marijuana use presented to ED with involuntary upward deviation of eye 1 day after using phencyclidine (PCP) for the first time. He did not have any other symptoms and was hemodynamically stable. All laboratory investigations were normal except urine drug screen which was positive for PCP. Patient was treated with IV diphenhydramine which improved his symptoms. Conclusion. Illicit drug abuse is a growing problem in our society with increasingly more patients presenting to ED with its complications. The differential diagnosis of acute dystonic reactions should be extended to include illicit drugs as the potential cause of reversible acute dystonias especially in high risk patients.

Raghib Syndrome Presenting as a Cryptogenic Stroke: Role of Cardiac MRI in Accurate Diagnosis

Raghib Syndrome is a rare developmental complex, which consists of persistence of the left superior vena cava (PLSVC) along with coronary sinus ostial atresia and atrial septal defect. This Raghib complex anomaly has also been associated with other congenital malformations including ventricular septal defects, enlargement of the tricuspid annulus, and pulmonary stenosis. Our case demonstrates an isolated PLSVC draining into the left atrium along with coronary sinus atresia in a young patient presenting with cryptogenic stroke without the atrial septal defect. Majority of the cases reported in the literature were found to have the lesion during the postmortem evaluation or were characterized at angiography and/or echocardiography. We stress the importance of modern day imaging like the computed tomography (CT) angiography and cardiac MRI in diagnosis and surgical management of such rare lesions leading to cryptogenic strokes.

O-014 Significant Acquisition Dose Reduction Maintains Diagnostic Quality of Biplane Cerebral Digital Subtraction Angiography

Purpose Digital subtraction angiography (DSA) remains the gold standard modality for evaluation, diagnosis, and treatment planning of several intracranial vascular abnormalities. However, patient radiation dose can be considerable with both diagnostic and especially complex neurointerventional procedures. Modern biplane flat-detector angiography units provide several possibilities for automatic dose reduction by modifying X-ray tube potential, current, pulse width, and filtration thickness. We aimed to investigate the feasibility of reducing the radiation exposure dose in diagnostic DSA examinations while preserving the overall image quality for diagnostic purposes. Materials and methods Following IRB approval and informed consent, a prospective study was performed on patients undergoing diagnostic cerebral DSA using biplane flat detector rotational fluoroscopy and angiography unit (Artis zee/zeego, Siemens). DSA images were acquired using a predefined manufacturer standard DSA program by selecting detector dose of 3.6 μGy/ frame (mean typical tube voltage (TTV): 80.6 kVP, mean tube current (TC): 230.6 mA, using focal spot size (FS) of 0.6 and inherent filtration) and reduced DSA detector dose of 1.2 μGy/frame (mean TTV: 73.6 kVP, mean TC: 153.5 mA, using FS of 0.3 with additional 0.1/0.2 copper filter) dose protocols for each patient. Using identical contrast agent, contrast injection rate, and fluoroscopy time, randomly selected internal carotid arteries or vertebral arteries and their contralateral equivalent arteries were injected to obtain standard radiation dose and low radiation dose AP and lateral DSA images, respectively. Images were not included for image quality assessment if any significant technical issue and/or flow limiting vascular stenosis/occlusion, or steal phenomenon from AV shunts were present. Image quality assessment was performed independently by two neurointerventionalists on a de-identified PACS workstation. A 5 point scale (5: Very good: excellent large and small vessel visualization; 4: Good: excellent large vessel and minimal compromise of small vessel visualization; 3: Average: diagnostic value for large vessel, but compromised small vessel visualization 2: Poor: compromised large and small vessel visualization; 1: Nondiagnostic) was used for qualitative evaluation of arterial, capillary, and venous phases of DSA images respectively. The total score was defined as the overall diagnostic value. Paired sample t-test and Wilcoxon’s signed rank test compared the kerma-area product (KAP) and scores assigned to image quality parameters, respectively. P value <0.05 was considered statistically significant. Results Twenty-three DSA image series were obtained from nine patients (8M/1F, mean age: 65.9 ± 9.16) undergoing diagnostic DSA. Mean KAP was significantly reduced by 60% or 2.5 fold (1408.90 ± 419.18 μGy/m2 vs. 557.08 ± 214.56 μGy/m2, P < 0.0001). No significant difference was observed between image quality scores assigned by the observers while assessing arterial (observer 1: P = 1.0; observer 2: P = 0.24), capillary (observer 1: P = 0.54; observer 2: P = 0.3), venous (observer 1: P = 0.14; observer 2: P = 0.7) phases, and overall diagnostic value (observer 1: P = 0.34; observer 2: P = 0.8). Conclusions Radiation exposure dose can be reduced significantly without compromising image quality for diagnostic purposes in cerebral DSA studies. Disclosures A. Honarmand: None. A. Shaibani: None. M. Hurley: None. B. Patel: None. V. Daruwalla: None. S. Ansari: None.

E-005 Short-term Outcomes of Acute Ischemic Stroke Patients with MCA/ICA Occlusion Excluded for Intra-arterial Reperfusion Therapy

Introduction Large-vessel occlusions account for 45% of patients with acute ischemic stroke (AIS) presenting to the emergency departments in the United States. Many of these patients may not be eligible candidates for intravenous tPA therapy; however, they may benefit from receiving intra-arterial therapy (IAT). Optimal patient selection plays a pivotal role in identification of those AIS patients who may benefit from IAT. However, no method has been introduced as the gold standard for patient selection among neurointerventionalists in the clinical practice. Therefore, many of the stroke patients with large vessel occlusion presenting in the acute setting do not receive IAT. We aimed to review the short-term outcome of AIS patients with large vessel occlusion who were not selected for IAT. Methods We retrospectively reviewed consecutive AIS patients with National Institute of Health Stroke Scale (NIHSS) score of more than 8 and CTA/MRA verified MCA/ICA occlusion who did not receive endovascular thrombectomy/thrombolysis treatment. Data were collected on demographics, initial NIHSS score, the cause for not being eligible for endovascular intervention, and mortality rate during the first 30 days. Eligibility for undergoing IA thrombectomy/thrombolysis treatment based on CT/MR perfusion imaging profiles was defined as CBV/DWI infarct core 20% infarct core. Results Thirty one AIS patients (19 F/12 M; mean age of 78.1(32–93; SD: ±13.44 years) were studied. Mean and median baseline NIHSS score were 20.06 (8–40; SD: ± 8.25) and 19, respectively. Mortality in the first 30 days was 38.7% (12/31) and 6 patients (20%) were referred to hospice. Among fourteen patients who did not undergo endovascular thrombectomy/thrombolysis reperfusion therapy due to the unfavorable perfusion profile, six patients expired and 4 patients were referred to the hospice, in the first 30 days. Seventeen patients were not intervened due to improvement in NIHSS score following receiving intravenous tPA, advanced age, severely high NIHSS score, and high risk clinical profile for intervention. Among these patients, six patients expired and two patients were referred to hospice. Conclusion In this cohort of patients, we observed relatively high mortality rate and poor short-term clinical outcomes in AIS patients with large vessel occlusion who were not selected for IAT. Patients excluded from receiving IAT using imaging-based methods, generally had worse outcomes compared with those patients who were selected based on clinical evaluation. Efforts should be made to develop a standard and accurate patient selection method for identification of the optimum number of AIS patients with large vessel occlusion who may benefit from IAT. Disclosures A. Honarmand: None. R. Beck: None. M. Soltanolkotabi: None. S. Ansari: None. A. Shaibani: None. V. Daruwalla: None. M. Hurley: None.

Myocardial strain analysis in patients with Heart Failure with preserved Ejection Fraction using bright blood cine MR images: A comparison with speckle-tracking echocardiography

Background Changes in myocardial strain parameters is of interest in patients with heart failure as an objective measure of disease severity. Speckle-tracking echocardiography (STecho) is the accepted standard of reference for myocardial strain analysis given superior temporal resolution; however, difficult acoustic windows and limited contrast to noise resolution can limit strain analysis. Preliminary work using deformation field analysis at steady state free precession (SSFP) cine MR imaging has shown that strain analysis at CMR is similar between conventional and highly accelerated GRAPPA cine acquisitions. The purpose of this study is to compare the strain values in patients with heart failure and preserved ejection fraction (HFpEF, left ventricular ejection fraction >50%) at SSFP cine MRI with ST-echo. Methods Retrospective analysis of Cardiac MR and echocardiographic images from 15 patients (5 men, avg age 61.2 yrs) with HFpEF. Cardiac MR images were obtained at 1.5 T (MAGNETOM Avanto, Siemens Medical Systems, Erlangen, AG) using GRAPPA factor 2 acceleration (temp res = 39.2 msec, spatial res = 1.5 × 1.5 mm, thickness = 6 mm). Myocardial strain analysis at Cardiac MR was performed using prototype software calculating Lagrangian strain from deformation field analysis (Siemens Corp, Corporate Technology, Princeton, NJ). Transthoracic echocardiography exams included apical 4-chamber and mid-ventricular short axis views. Left ventricular (LV) mid ventricular average and peak systolic radial and circumferential strains as well as longitudinal strain data was calculated. Peak and average right ventricular (RV) longitudinal strain was also obtained. CMR and ST-Echo derived strain indices were compared using the Pearson correlation. Inter and intraobserver variance was assessed for CMR-derived RV and LV longitudinal strain analysis using the intraclass correlation coefficient (ICC). Results