ischemia

Delayed cerebral ischemia (DCI) is one of the main complications of spontaneous subarachnoid haemorrhage and one of its causes is the cortical spreading depolarizations (CSDs). Cortical spreading depolarizations are waves of neuronal and glial depolarizations in which there is loss of neuronal ionic homeostasis with potassium efflux and sodium and calcium influx. In damaged brain areas and brain areas at risk, such as those adjacent to subarachnoid haemorrhage (SAH), CSDs induce microvascular vasoconstriction and, therefore, hypoperfusion and spread of ischemia. Several studies have been devoted to minimize secondary injuries that occur hours to days after an acute insult. Ketamine, a drug until recently contraindicated in the neurosurgical population for potentially causing intracranial hypertension, has re-emerged as a potential neuroprotective agent due to its pharmacodynamic effects at the cellular level. These effects include anti-inflammatory mechanisms, and those of microthrombosis and cell apoptosis controls, and of modulation of brain excitotoxicity and CSDs. A literature review was performed at PubMed covering the period from 2002 to 2019. Retrospective studies confirmed the effects of ketamine on the control of CSDs and, consequently, of DCI in patients with SAH, but did not show improvement in clinical outcome. The influence of ketamine on the occurrence/development of DCI needs to be further confirmed in prospective randomized studies

Background: Heparin-induced thrombocytopenia/thrombosis (HIT/T) is characterized by a fall in platelet count 5-10days after starting heparin therapy and is diagnosed with specific 4-T clinical features and laboratory tests. This complication is relatively common in Cardiothoracic surgery patients. Objective: To evaluate the positive and negative predictive value of various HIT laboratory tests and assess any correlation between HIT, the underlying diagnosis, underlying procedure, and mechanical cardiac devices. Patients and methods: The patient’s medical records were correlated with two laboratories HIT diagnostic tests, the pan-specific screening test with IgG, IgA, and IgM antibodies, followed by HIT specific IgG ELISA. Results: Total n = 80 patients were assessed, 48% (n = 38) were HIT screen pan-specific negative and 50% (n = 40) were HIT pan-specific positive and 2 cases were inconclusive. 17% (n = 14) were both pan-specific and specific HIT IgG ELISA positive. There were 5 atypical cases. One patient had Eosinophilic myocarditis and was HIT ELISA IgG neg. Argatroban was given on clinical grounds with successful recovery. One patient with Sarcoidosis had an aggressive course and received IV Immunoglobulin (IVIG) but succumbed secondary to liver failure. One patient progressed to gut ischemia and had surgical intervention but succumbed. Two patients with mechanical heart valves were on Argatroban but relapsed and responded to IVIG therapy. Conclusion: Our study indicates that 9/16 (> 50%) HIT-positive patients had valve replacement or cardiac devices suggesting that like knee arthroplasty there is a high incidence of HIT in patients with mechanical heart valves and cardiac devices and this warrants further prospective study. 

Aim: To examine the relationship between the levels of HbA1c and hospital admission rates.Methods: We recorded HbA1c levels of all diabetic patients in Tripoli University Hospital over one year.Results: The mean HbA1c was 8.03%, with no difference between males and females. Over half of patients (56.5%) were admitted through their diabetes was well-controlled. Over half of the patients with type 1 diabetes (57/102, 55.9%) had a high HbA1c at admission compared to 42.1% of patients with type 2, who were mainly admitted with HbA1c level within the acceptable range set for this study. The HbA1c level was positively and significantly correlated with the length of hospital stay (R = 0.93, p = 0.000), and was significantly associated with hyperglycemia, diabetic ketoacidosis, coronary artery disease, limb ischemia, cataract, osteomyelitis, and non-alcoholic steatohepatitis.Conclusion: HbA1c is correlated significantly with hospitalization in type 1 diabetes but not in type 2.

Percutaneous coronary angioplasty is a minimally invasive procedure aimed at unclogging a coronary artery with a low complication rate (with a serious complication rate of 3% to 7% and a mortality rate of 1.2%). Device entrapment during PCI is a rare but life-threatening complication that occurs in < 1% of PCIs and balloon entrapment comes second after coronary guidewires. We present the case of 68-years-old man, smoker, hypertensive and type2 diabetic that presents angina with evidence of ischemia on myocardial tomoscintigraphy and in whom the radial coronary angiography reveals a tight calcified mid LAD stenosis. During his PCI and after dilatation with an NC balloon 2.5 × 12 the latter refuses to deflate and remains trapped in the lesion with the appearance of pain and ST-elevation despite several attempts to dilute the product in the inflator and to burst it by overexpansion. Traction on the balloon resulted in the deep intubation of the guiding-catheter, which comes in contact with the trapped balloon, and the rupture of the latter’s hypotube, which remains inflated at the site of the lesion and mounted on the 0.014 guidewire. We put a second 0.014 guidewire distally in the LAD and twisted with the distal part of the first guidewire, then we introduced a second balloon 2.0 × 20 over the second guidewire until the distal part of the guiding-catheter and inflated to trap the stucked balloon. We gradually removed this emergency assembly that allowed us to retrieve the trapped balloon. The control injection revealed a thrombotic occlusion of the LAD treated by thrombectomy and anti-GPIIbIIIa followed by a DES 2.75 × 28 placement. The patient was discharged 48 hours later with a good LVEF. The possible balloon entrapment mechanisms are an acute recoil of a highly calcified lesion with compression of the incompletely deflated balloon, which seems to be the case in our patient, strangulation of the proximal balloon end by the guiding-catheter if the balloon is removed before complete deflation and break or bend of the hypotube. The solutions in case of undeflatable balloon entrapment are to dilute the product in the inflator, to burst it by overexpansion, to pierce it through a stiff guidewire (or through its other end on a Microcatheter or OTW balloon), to cut its outer part and let it empty passively, to introduce a second guide-wire and perform a Buddy-Balloon or to transfer the patient to Surgery. Material entrapment remains a rare but life-threatening complication, its eviction requires the choice of material size and gentle manipulations (small balloons in the event of a calcified lesion) and its management uses different techniques, the choice of which depends on the clinical and anatomical situation. 

Portal vein thrombosis (PVT) is a rare condition that may congest bowel venous drainage and cause mesenteric ischemia. In acute settings, gastrointestinal bleeding (GIB) is rare, and acute abdominal pain is the most common clinical presentation. A 24-year-old man who presented with acute abdominal pain and a single episode of hematemesis is reported. Workups revealed evidence of thrombosis in the portal vein, but upper endoscopy was incapable to detect the source of the bleeding. We discuss the possible scenarios for the GIB in this case and review similar reports in the literature.

SARS-CoV-2 is a new pandemic infection that affects at the beginning the upper respiratory system, and, successively, all the organisms, due to cytokine storm, with serious consequences that can reach death. The aim of this work was the observation of the nasal mucosa of enrolled 60 patients, resulting negative for two weeks to the molecular swab for SARS-CoV-2, versus the control group. Rhino-fibroscopy and nasal cytology of nasal mucosa were performed for both the investigated groups. The observation of the samples showed the occurrence of plasmablastic lymphocytes and Downey II lymphocytes type. The former type of lymphocytes was prevalent against the second one, probably because of an immunological “scar”. The rhino-fibroscopy showed a “pseudo ischemia of nasal submucosa” at pre and pericranial levels, not occurred in the control group.The occurrence of atypical lymphocytes in the nasal smear was analog to that observed in the blood peripheral smear, probably caused by mechanisms of local immune reaction and dysregulation like those observed in other virus infections. Our findings suggest that the nasal mucosa study through the nasal cytology, can represent an important predictive tool of the SARS-CoV-2 infection.

Aims: There is no study in the literature about ischemia-modified albumin (IMA) and hepatocyte growth factor (HGF) levels in amniotic fluid for Down syndrome cases. The aim of this study was to investigate the changes of IMA and HGF in Down syndrome cases at 16-20 weeks of gestation compared to normal fetuses.Methods: For this prospective case-control study, following reaching the number of 20 women (study group) who had the prenatal diagnosis of Down syndrome, maternal and gestational age-matched pregnant women with normal constitutional karyotype were selected for the control group (n = 74) from the stored amniotic fluid samples. Results: Mean women and gestational ages were comparable between the two groups. Amniotic fluid IMA (1.32 ± 0.13 vs. 1.11 ± 0.11 ABSU, respectively, p < 0.001) and HGF (2743.53 ± 1389.28 vs. 2160.12 ± 654.63 pg/mL, respectively, p = 0.008). Levels were significantly higher in pregnant women having Down syndrome fetuses compared with women having normal fetuses. The amniotic fluid IMA levels for the diagnosis of Down syndrome, and the sensitivity and specificity were calculated as 95.0% and 71.6% for the limit value 1.171 cm3, respectively. Conclusion: In cases with suspected Down syndrome, the diagnosis of Down Syndrome may be made in approximately 1 hour with high sensitivity and specificity by measuring the IMA level in the amniotic fluid sample taken for fetal karyotyping.

Objective: Assessment of heart rate variability (HRV) is a non-invasive and reliable method to evaluate autonomic disorders after cerebral ischemia. The present study was conducted to investigate the therapeutic potential of IC87201 in reducing post-stroke cardiac dysfunction. Materials and methods: Cerebral ischemia was induced by the middle cerebral artery occlusion (MCAO) method in 15 anesthetized adult male rats in three MCAO, MCAO+ DXM, and MCAO+ IC87201 groups, for one hour. Electrocardiogram was recorded before, and 48 hours after ischemia and drug administration, and HRV parameters were calculated from R-R intervals. In the treatment groups, IC87201 and Dextromethorphan hydrobromide monohydrate (DXM) were injected after an ischemic period. Results: After brain ischemia, the R-R interval decreased and consequently heart rate increased. The R-R intervals were used to extract the HRV frequency and time domains, including normalized low frequency (LF), high frequency (HF), LF/HF ratio, and standard deviation of R-R interval (SDRR). Normalized LF and LF/HF ratio enhanced 48 hours after ischemia, while normalized HF and SDRR significantly reduced compared to the pre-ischemic state. All HRV parameters had returned to their pre-ischemic level 48 hours after IC87201 and DXM administration, except SDRR, which recovered only in the IC87201 administered group. Conclusion: Based on our findings, it can be concluded that cerebral ischemia significantly worsens HRV parameters as a result of sympathetic overactivity. These changes were reversed by administering DXM and IC87201, but IC87201 has generally been more effective in lowering lesions. As a result, IC87201 can be introduced as an effective substance for the treatment of post-ischemic cardiac side effects.

Ischemia-Reperfusion Injury (IRI) is the outcome of two intertwined pathological processes resulting from the shortage of blood flow to tissues and the subsequent restoration of circulation to a previously ischemic area. IRI (sometimes just one side of the dyad) remains one of the most challenging problems in several branches of emergency medicine. Mitochondrial and endoplasmic reticulum dysfunction is a crucial pathological factor involved in the development of IRI. The sigma-1 receptor (Sig1-R) is an intracellular chaperone molecule located between the mitochondria and endoplasmic reticulum with an apparent physiological role in regulating signaling between these cell organelles and serves as a safety mechanism against cellular stress. Therefore, amelioration of IRI is reasonably expected by the activation of the Sig1-R chaperone. Indeed, under cellular stress, Sig1-R agonists improve mitochondrial respiration and optimize endoplasmic reticulum function by sustaining high-energy phosphate synthesis. The discovery that N, N-dimethyltryptamine (DMT) is an endogenous agonist of the Sig1-R may shed light on yet undiscovered physiological mechanisms and therapeutic potentials of this controversial hallucinogenic compound. In this article, the authors briefly overview the function of Sig1-R in cellular bioenergetics with a focus on the processes involved in IRI and summarize the results of their in vitro and in vivo DMT studies aiming at mitigating IRI. The authors conclude that the effect of DMT may involve a universal role in cellular protective mechanisms suggesting therapeutic potentials against different components and types of IRIs emerging in local and generalized brain ischemia after stroke or cardiac arrest.

Ischemic Heart Disease (IHD) remains a significant cause of morbidity and mortality worldwide. We present a case report of a 54-year-old individual presenting with symptoms suggestive of IHD, including palpitations and chest heaviness. Utilizing a Spandan device at home, the patient detected anteroseptal and lateral wall ischemia, prompting consultation with a cardiologist. Subsequent diagnostic evaluations revealed Left Ventricular Hypertrophy (LVH), concentric LVH, regional wall motion abnormality, and Grade I diastolic dysfunction. Hypertension and dyslipidemia were identified as prominent risk factors, with additional findings of carotid artery disease. Management strategies included antihypertensive medications, lipid-lowering therapy, and lifestyle modifications. This case underscores the complexity of diagnosing and managing IHD, highlighting the importance of comprehensive assessment and multidisciplinary care in optimizing patient outcomes.

Spontaneous Coronary Artery Dissection (SCAD) represents a significant cause of acute coronary syndrome (ACS) in patient populations with low-risk cardiovascular profiles and, therefore can be sometimes underdiagnosed. On the other hand, it often preserves the typical clinical presentation of ACS which makes coronary artery angiography (CAG) execution mandatory. A 62-year-old woman with a history of recurrent SCAD presented to the emergency department for a new episode of acute chest pain with troponin elevation. CAG revealed an ambiguous angiography image suggesting a sub-occlusive type 2 SCAD involving the distal segment of the left circumflex artery. The patient was managed conservatively due to the absence of ongoing ischemia or hemodynamic instability. At the seven-day follow-up, a computed tomography coronary angiography (CTCA) was performed to better assess SCAD and detect concomitant associated arteriopathies. Optimized medical therapy was prescribed at the discharge and at one-month follow-up, no recurrence of symptoms was referred.

Atherosclerosis Ischemic Cardiovascular Disease (ASICD), one of the leading causes of global deaths, is mainly caused due to the development of plaque on the inner walls of arteries of the human heart. Ischemia refers to the lack of enough oxygen (O2), nutrient delivery, and improper waste removal in the cardiac cells. About 90% of cardiovascular diseases in the present world are due to the formation of lipid/cholesterol-based plaques that can form under the lining of the smooth epithelial blood cells. In the US, a study published in the Journal of the American College of Cardiology estimated that poor diet is responsible for about 45% of Cardiovascular Disease. Atherosclerosis doesn’t cause much effect until and unless the plaque becomes unstable due to the accumulation of thrombus that shows Acute Coronary Syndrome. Acute Coronary Syndrome is the result of blockage of blood vessels leading to Myocardial Infarction (Unstable Angina Pectoris). Cardiac Cells require a sufficient amount of Oxygen to function properly. Thus, the demand and supply of oxygen to the cardiac cells should be properly balanced. Atherosclerosis Ischemic Cardiovascular syndrome can worsen if the person is more involved in exercise or emotional stress because at that time their body requires higher oxygen but blood flow gets disrupted due to the formation of plague. Later in the paper, we will discuss the New York Heart Association classification, followed by the top 3 poor diets that are considered to be increasing the cases of cardiovascular disease around the world.

Uvular injuries are uncommon after general anesthesia and can result from direct trauma to the posterior part of the soft palate or compression and restriction of blood flow to the uvula caused by the inadvertent placement of the airway or suction devices in the oral cavity. There have been cases of inflammation and ulceration occurring in the midline oropharyngeal structures such as the uvula after general anesthesia with a tube or laryngeal mask airway, even in the absence of direct trauma or infection, presumably due to compression ischemia. While sore throat following general anesthesia is a common symptom, it is important to evaluate any severe or persistent pain to exclude uvulitis. Here we present a case of uvulitis that developed after the insertion of a flexometallic endotracheal tube using the midline technique during C-Mac video laryngoscopy. We also emphasize the measures that can be implemented to prevent such a complication. The entrapment of the uvula during intubation often goes unnoticed due to limited oral space after insertion of the video laryngoscope blade, with the intubating anesthetist staying focused on the monitor. This complication following the use of a C-Mac video laryngoscope has not been previously documented.

Pseudotumoral calcinosis (CPT) is a condition characterized by the deposition of calcium phosphate crystals in the periarticular tissues, forming large calcified masses. Although the pathophysiology of CPT is not fully understood, an increase in the calcium-phosphate product beyond the precipitation threshold and severe hyperparathyroidism appear to play a significant role. Treatment remains controversial, with surgical excision often recommended. We report a case of CPT in a 74-year-old diabetic patient undergoing chronic hemodialysis who experienced progressively worsening pain in the left hip for six months, along with mobility difficulties. A CT scan revealed a calcified mass on the posterior thigh, likely explaining the electric shock-like pain, as well as compression of the superficial femoral artery causing decubitus pain resembling critical limb ischemia. The biological assessment showed elevated calcium-phosphate levels and hyperparathyroidism. Surgical excision is not indicated due to the mass’s proximity to vascular and nerve structures. This case highlights the diagnostic and therapeutic challenges of CPT, emphasizing the need for iterative angioplasties, considering that this condition is rare in chronic hemodialysis patients with calcified periarticular masses.

Background: Studies explored the therapeutic role of agents inhibiting RAS in epilepsy. Fewer studies addressed the electrophysiological changes associated with angiotensin converting enzyme inhibitors (ACEIs) in terms of sustained seizures (status epilepticus). Sodium valproate (SVPA), a broad-spectrum anticonvulsant, has been associated with adverse cardiac events upon long-term use, in contrast to the beneficial role of ACEIs in cardiovascular disorders.  This work explored the potential effects of ramipril, an ACEI, compared to SVPA, on the behavior, and electrophysiology of the brain and heart in a rat model of status epilepticus. The dose dependent pattern of the presumed ramipril activities was investigated. Methods: Adult male rats were assigned into seven groups, controls, IP pyridostigmine (36 mg/kg)-induced status epilepticus (PISE), oral SVPA (5 mg/kg), and three groups receiving oral ramipril at respective doses of 5 (R5), 10 (R10), and 20 mg/kg (R20). Rat behavior was assessed using Racine’s motor convulsion scoring for 10 minutes.  Blood pressure was recorded, and electroencephalography (EEG) and electrocardiography (ECG) were performed on the sedated rats 24 hours after recovery. Results: Despite the partial behavioral improvement of motor convulsions with R5 and R10 exhibited epileptogenic activity, as indicated by the increased relative power of fast and slow gamma waves and total EEG power. R10 triggered arrhythmia and cardiac ischemia as indicated by absence of P wave, along with ST elevation and tall T wave, slowed heart rate and prolonged QRS, QTc, and RR intervals. Conclusion: PISE was resistant to sodium valproate and ramipril. Ramipril at low and moderate doses induced epileptogenic activity and, especially at moderate dose, precipitated cardiac ischemia and arrhythmia. SummaryThe debatable role of ramipril in epilepsy was studied in a rat model of pyridostigmine-induced status epilepticus, compared to sodium valproate. Increasing ramipril doses did not resolve status epilepticus in rats. Instead, low and moderate doses exhibited epileptogenic activity, opposite to high dose ramipril and sodium valproate. Blood pressure was dose-dependently reduced with ramipril. Electrocardiography showed evidence of cardiac arrythmia and ischemia, especially with the moderate ramipril dose. The behavioral and EEG indices correlated with systolic blood pressure and ECG changes.

Left ventricular thrombus (LVT) is a life threatening complication following acute coronary syndromes but in modern era its incidence has reduced since the introduction of primary percutaneous intervention. LVT is associated with higher morbidity and mortality due to its thromboembolic events and major adverse cardiac events (MACE). This is a case report of 30-year-old male  who presented with acute abdomen and left ventricular thrombus. CECT abdomen revealed superior mesenteric artery (SMA) thrombosis and echocardiography revealed severe ventricular dysfunction (ejection fraction, EF<30%) with global hypokinesia and LVT. SMA thrombosis is fatal and if left unattended can lead to intestinal ischemia and gangrene, hence immediate intervention is warranted. This patient had undergone emergency laparotomy under general anesthesia for the resection of gangrenous jejunal segment with mucous fistula . This case report discusses perioperative management considerations in such cases.