Volume 102 ·  Issue 45 ·  2022

Cardiogenic stroke, manifested as a clinical syndrome in which emboli from the heart and aortic arch pass through the circulation and cause cerebral artery embolism and corresponding brain dysfunction, accounts for 20% to 30% of all ischemic strokes. Regarding the etiological classification, the boundary between cardiogenic stroke and cryptogenic stroke, especially embolic stroke of undetermined source (ESUS), as well as aortic arch atheromas categorization remain uncertain. Concerning the diagnosis, the criteria need to be formulated and unified, and thus the author proposes new diagnostic criteria. With regard to the treatment, anticoagulation therapy should be started or restarted several days to several weeks after the onset of stroke (e.g., atrial fibrillation-related), and treatment during acute phase and for prevention of stroke recurrence should be initiated after multi-disciplinary consultation.

Ischemic stroke is usually regarded as a neurological disease, but cardiogenic cerebral embolism is actually one of the most common identifiable causes of ischemic stroke. According to the origin of embolus (left heart/right heart system) and related structural abnormalities, this article expanded and refined the classification definition of cardiogenic cerebral embolism, and proposed an improved classification method of ischemic stroke (PUMCH-ISC). In addition, this article gave a practical clinical screening program for cardiovascular physicians according to different causes of stroke, and sorted out the prevention and treatment strategies and progress of common causes of cardiogenic cerebral embolism, aiming to help cardiovascular physicians and neurologists improve the screening, diagnosis and accurate prevention and treatment of cardiogenic cerebral embolism.

Atherosclerosis IS a chronic progressive disease that IS more common in middle-aged and elderly people, often involving cardiovascular and cerebrovascular diseases. Clinically, atherosclerotic ischemic stroke (IS) or transient ischemic attack (TIA) often coexist with coronary heart disease (CHD). Compared with those without CHD, most IS patients with CHD are more severe, have a higher risk of death and have a worse prognosis. According to the etiology and clinical characteristics, this consensus divided them into three categories: brain-heart syndrome, acute coronary syndrome (ACS) -related IS/TIA, and atherosclerotic IS/TIA coexisting with CHD, and formulated corresponding diagnostic criteria. Intravenous thrombolysis and/or endovascular therapy were performed during the acute treatment window for stroke, and staged or concurrent carotid intervention [carotid stenting (CAS) or carotid endarterectomy (CEA)] + myocardial revascularization [coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI)] were performed for CHD, as appropriate, and perioperative management was performed. Measures such as risk factor control and lifestyle change were given in secondary prevention, and cardiac and neurological rehabilitation were actively carried out.

With the aging of the population, osteoporosis becomes an increasingly public social problem, and bone fracture is the most serious complication of osteoporosis. Moreover, the incidence of osteoporotic fractures is increasing year by year, which is harmful and seriously endangers healthy aging. However, the current diagnosis and treatment status still needs to be improved. In order to promote the standardized diagnosis and treatment of osteoporotic fractures, optimize their early identification, diagnosis and treatment strategies, prevent re-fractures, and improve the quality of life and health level of patients and risk groups with osteoporotic fractures, the Osteoporosis Prevention and Rehabilitation Professional Committee of Chinese Association of Rehabilitation Medicine took the lead and formulated this consensus through the improved Delphi method for the reference of medical workers.

To analyze the clinical features, risk factors and prognosis of idiopathic dilated cardiomyopathy (DCM) complicated with ischemic stroke (IS) (DCM-IS).

The clinical data of patients with idiopathic DCM (n=613) in Beijing Anzhen Hospital, Liangxiang Hospital and Fuxing Hospital from January 2016 to December 2020 were retrospectively collected, and among them, 123 cases were DCM-IS. Clinical features of patients with DCM-IS were summarized and multivariate logistic regression model was utilized to analyze the independent risk factors of DCM-IS. Furthermore, 1-year follow-up was conducted and Kaplan-Meier curve was adopted to analyze the prognosis of DCM, using all-cause death and heart transplantation as adverse outcomes.

Among the 70 patients with DCM-IS, 6 patients (8.6%, 6/70) were in accordance with the subtype of large artery atherosclerosis, and 47 patients (67.1%, 47/70) were in line with the subtype of cardiogenic embolism, and small artery occlusion subtype (ie, lacunar infarction) were detected in 17 cases (24.3%, 17/70). Hypertension [odds ratio (OR)=1.617, 95% confidence interval (CI): 1.049-2.491, P=0.029], hyperlipidemia (OR=1.918, 95%CI: 1.198-3.073, P=0.007), atrial fibrillation (AF) (OR=1.617, 95%CI: 1.016-2.572, P=0.043), lower estimated glomerular filtration rate (eGFR) (OR=0.986, 95%CI: 0.977-0.996, P=0.005) and a higher incidence of intracardiac thrombus (OR=6.127, 95%CI: 3.174-11.827, P<0.001) were risk factors for DCM-IS. The overall 1-year survival rate was lower in DCM-IS patients (70.7%) than DCM patients without stroke (83.6%, P=0.004), and the main causes of death included obstinate heart failure (3 cases of DCM-IS, and 5 cases of non-DCM-IS) and malignant arrhythmia (DCM-IS) (22 cases of DCM-IS, and 18 cases of non-DCM-IS).

Among IS patients with idiopathic DCM, cardioembolism is the most common, followed by lacunar infarction, and the large-artery atherosclerotic subtype is the least common.Hypertension, hyperlipidemia, AF, lower eGFR value and higher incidence of intracardiac thrombus are risk factors for DCM-IS. DCM patients complicated with IS have poor short-term prognosis, and obstinate heart failure and malignant arrhythmia are their main causes of death.

To investigate the prevalence of atrial cardiomyopathy in patients with different types of acute ischemic stroke and its relationship with cryptogenic stroke.

Patients with acute ischemic stroke within 7 days of onset who were admitted to the Department of Neurology of the First Affiliated Hospital of Zhengzhou University from January to September 2019 were prospectively and consecutively enrolled. All included patients were classified according to TOAST classification of ischemic stroke. Chi-square test was used to compare the prevalence of atrial cardiomyopathy among patients with different TOAST classifications. Multivariate logistic regression model was used to analyze the related factors of cryptogenic stroke.

A total of 1 098 patients with acute ischemic stroke were enrolled in the study, including 661 males and 437 females, with a median age [M(Q₁,Q₃)] of 61 (53, 68) years. The prevalence of atrial cardiomyopathy in patients with cryptogenic stroke[53.5% (46/86)] was higher than that in patients with large artery atherosclerosis [38.0%(63/166), P=0.018] and small vessel occlusion [19.4%(37/191), P<0.001], but was lower than that of patients in the cardioembolic group [97.3% (72/74), P<0.001]. Multivariate logistic regression analysis showed that atrial cardiomyopathy was an associated factor for cryptogenic stroke (OR=2.945, 95%CI: 1.766-4.911, P<0.001).

Atrial cardiomyopathy is associated with cryptogenic stroke. The prevalence of atrial cardiomyopathy in patients with cryptogenic stroke is higher than that in patients with large artery atherosclerosis and small vessel occlusion, but lower than that in patients with cardiac embolism.

To evaluate the long-term efficacy of treatments on cryptogenic ischemic cerebral vascular disease (CICVD) with patent foramen ovale (PFO) and analyze prognostic factors, so as to provide the references for the treatment and secondary prevention of PFO related cerebral vascular disease.

Consecutive patients with CICVD and PFO related right-to-left shunting confirmed by transesophageal echocardiography or transcranial doppler bubble test, who admitted to the Department of Neurology in Xuanwu Hospital from May 1, 2012 to December 31 2021 were enrolled. All the patients underwent hypercoagulability screening, and the degree of hypercoagulability was evaluated by a scoring scale. Each PFO was classified as either high-risk or low-risk according to its anatomic features. Patients were divided into the drug treatment group (including antiplatelet and anticoagulation therapies) and transcatheter PFO closure group. After follow-up, the recurrence of cerebral ischemic events were compared between the two groups by Kaplan-Meier method, the prognostic factors were analyzed by multifactorial Cox′s regression model.

A total of 117 patients were recruited, 10 patients were lost to follow-up, and 107 patients were included in the final analysis, consisting of 66 males and 41 females, with age ranging from 14 to 67 years and the follow-up period of 1 229 (45, 3 508) d. The recurrence rate of cerebral ischemic events was 6% (4/66) and 7% (3/41) for the drug treatment group (66 cases) and closure group (41 cases), respectively, and residual shunting was detected in all patients with recurrent events in the closure group. Cumulative hazard curve indicated that there was no significant difference of recurrence risk of cerebral ischemic events between the two groups (cumulative recurrence rate: 17.9% in the closure group vs 7.1% in the drug treatment group, χ²=0.368, P=0.544), and the insignificance persisted even in subgroup analysis of CICVD patients with either high-risk (χ²=0.685, P=0.408) or low-risk PFO (χ²=0.072, P=0.789). Cox′s regression model indicated that hypercoagulability related factor score was an independent predictor of recurrent cerebral ischemic events (HR=2.079, 95%CI 1.069-4.045, P=0.031) after adjusting for high-risk PFO, PFO closure and other confounding factors. Moreover, a rising trend of cumulative recurrence rate was observed as the score got higher (P=0.046).

For CICVD patients with either high-risk or low-risk PFO, the significant value of drug treatment as the first-line therapy for PFO related CICVD should not be ignored, which awaits further discussion. The abnormality of hypercoagulability related factors might increase the recurrent risk of cerebral ischemic events, which calls for more attention and should be screened and treated with corresponding medication.

To investigate the characteristics of delayed high-degree atrioventricular block (DHAVB) after transcatheter aortic valve replacement (TAVR).

One hundred and seventy-six patients who underwent TAVR with a self-extending valve between May 2014 and November 2018 in the Department of Cardiology, West China Hospital of Sichuan University, were retrospectively enrolled, including 101 males and 75 females, aged 54-92 (73±7) years, and the data were collected during the perioperative and 30 d follow-up periods. According to the occurrence of HAVB after TAVR, 160 patients were divided into no-HAVB group (145 cases) and DHAVB group (15 cases), except 16 patients who developed HAVB within 2 days after TAVR. Baseline data, intraoperative data, and immediate postoperative ECG characteristics were compared between the two groups, and logistic regression models were used to analyze the factors associated with the occurrence of DHAVB after TAVR. Meanwhile, the diagnostic ability of the postoperative routine 12-lead ECG for DHAVB was evaluated using the ambulatory ECG findings as the standard diagnosis.

The incidence of DHAVB was 8.5% (15/176) and occurred at 5 (4, 6) d. Compared with the no-HAVB group. The percentage of no new conduction block on the immediate postoperative ECG was lower in the DHAVB group [6/15 vs 66.2%(96/145), P=0.044], and the percentage of new right bundle branch block on the immediate postoperative ECG was higher [4/15 vs 3.4%(5/145), P=0.002]. Multifactorial logistic regression analysis showed that right bundle branch block on the immediate postoperative ECG [OR (95%CI):6.60 (1.26-34.47), P=0.025] was an associated factor for the development of DHAVB after TAVR. The specificity of postoperative routine 12-lead ECG for the diagnosis of DHAVB was 100% (145/145), but the sensitivity was only 73.3% (11/15).

The incidence of DHAVB after TAVR is also high in Chinese. The immediate postoperative ECG characteristics of patients who underwent TAVR are associated with DHAVB events, and applying these characteristics to risk stratify patients may optimize the management of DHAVB after TAVR.

To discuss the application value of hard tissue section in the clinicopathology diagnosis.

From March 2021 to December 2021, bone slices of 19 patients (1 patient with osteochondroma, 2 patients with chondrosarcoma, 4 patients with osteosarcoma, 2 patients with fibrous dysplasia, 2 patients with bone metastasis from thyroid papillary carcinoma, 2 patients with osteomyelitis, 4 patients with giant cell tumor of bone, 2 patients with Ewing sarcoma) and 16 hemopathy patients were collected from the Department of Pathology, Shanghai Sixth People′s Hospital. Of the osteopathy patients, there were 14 male and 5 female with a median age of 31 (10-66) years. Meanwhile, there were 7 male and 9 female with a median age of 28 (16-65) years among these hemopathy patients. Thirty-five cases were treated with modified hard tissue slicing technique and paraffin embedding technique, respectively. The advantages and disadvantages of the two methods for clinical diagnosis of bone disease were compared by Hematoxylin-Eosin staining (H&E staining), immunohistochemical staining (IHC), fluorescence in situ hybridization (FISH) and Sanger sequencing.

The improved resin-embedded method showed better histological morphology and cell structure. Besides, the expression of Ki67, SATB2, CD34, SMA, CD68,MPO,CD4 and CD33 in immunohistochemical staining in bone tissues which were embedded in resin were more clear in the accurate positive localization than those using paraffin-embedded. MDM2 of FISH exhibited a higher fluorescence intensity and more accurate location. Meanwhile, both methods treated with Sanger sequencing met the requirements of DNA purity and mutation detection.

The improved hard tissue section method is simple and short time-consuming, which is suitable for optimizing the clinical bone and bone marrow pathological diagnosis process.

To explore the application value of plasma proteomics in the diagnosis and pathogenesis of high altitude polycythemia (HAPC).

Ten patients with HAPC in Qinghai Provincial People′s Hospital from January 2020 to January 2021 were selected as the experimental group, including 4 males and 6 females, aged (46±4) years. Ten healthy controls at the same altitude in the same period were selected as the control group, including 5 males and 5 females, aged (44±4) years. The differential proteins were identified and quantified by high performance liquid chromatography-mass spectrometry (HPLC-MS), and the gene ontology (GO) functional enrichment analysis, the Kyoto Encyclopedia of Genes and Genomes (KEGG) functional enrichment analysis and interaction network analysis were conducted for the selected differential proteins.

A total of 117 differential proteins with quantitative values were screened from the experimental group and the control group, 45 significantly up-regulated proteins with quantitative values only in the experimental group, 40 significantly down-regulated proteins with quantitative values only in the control group, and 32 differentially expressed proteins with quantitative values in both experimental and control groups were detected. Compared with the control group, 11 of the 32 differentially expressed proteins in the experimental group were down-regulated and 21 were up-regulated. The results of GO functional enrichment analysis showed that the biological processes involved by differential proteins mainly included immune response, complement activation, activated protein cascade and coagulation system. The results of KEGG function enrichment analysis showed that the main biochemical metabolic pathways and signal transduction pathways involved by differential proteins were axon guidance, lysosomes, cell adhesion molecules, lipid and atherosclerosis, hematopoietic cell lineage and cholesterol metabolism. The abundant domains are mainly in immunoglobulin-like domain, EGF-like domain, fibronectin type Ⅲ superfamily, serine proteases, Sushi/SCR/CCP superfamily. The results of differential protein interaction analysis showed that the interaction score was>700, and the top 10 differential proteins with the largest number of nodes were MPO, RPS27A, ARG1, GM2A, TIMP1, CRP, FABP5, HBB, S100A7 and RHOA, respectively.

Plasma proteomics analysis technique is helpful to identify the related protein markers in the development of HAPC, and provide reference for the diagnosis and pathogenesis of HAPC.

From January 1, 2015 to December 31, 2021, 94 patients who were diagnosed with atrial fibrillation (AF) associated anterior circulation large vessel occlusion stroke and underwent mechanical thrombectomy in the First Affiliated Hospital of Dalian Medical University were retrospectively collected, including 52 patients in the direct mechanical thrombectomy (dMT) group and 42 patients in the bridging therapy (BT) group. All patients received stent thrombectomy, and the BT group received intravenous thrombolytic therapy with alteplase within 4.5 hours.There were no significant differences in 7 d National Institute of Health Stroke Scale (NIHSS) score[12.0 (5.2, 42.0) vs 10.0 (6.0, 25.8)], incidence of hemorrhage transformation [44.2%(23/52) vs 45.2%(19/42)], symptomatic intracranial hemorrhage[11.5%(6/52) vs 11.9%(5/42)],90 d mortality[34.6% (18/52) vs 38.1% (16/42)]between the two groups(all P>0.05). The rate of 90 d good prognosis in dMT and BT groups was 36.5% (19/52) and 35.7% (15/42), respectively, and the difference was not statistically significant(OR=1.45, 95%CI: 0.39-3.37, P=0.805). The number of stent passes[2(1,3) vs 1(1,2)] and the vessel recanalization time [(81±41)min vs (57±29)min] in the BT subgroup of middle cerebral artery (MCA) occlusion were longer than those in the dMT group (both P<0.05).Therefore, direct thrombectomy has similar efficacy and safety as bridging therapy in the treatment of AF related anterior circulation large vessel occlusive stroke, which is worthy of further research and verification.

The treatment of Crohn's disease is mainly based on drugs, while refractory Crohn's disease may require endoscopic or even surgical intervention. Especially for patients with postoperative relapse, how to weigh the advantages and disadvantages of drugs, endoscopy and reoperation is a clinical problem. This paper reports a case of a 17-year-old boy with refractory Crohn's disease with recurrent episodes after treatment with hormones, azathioprine, surgery, adalimumab and infliximab. Only small intestinal anastomotic ulcers were found under endoscopy under the condition of asymptomatic, weight gain but increased inflammatory indicators. At this time, it is difficult to decide how to adjust the drug, whether to choose endoscopic intervention or surgery. Finally, through multidisciplinary joint consultation and joint decision-making between doctors and patients, the patient chose to insert the contrast tube through the endoscopic forceps tube. After the injection of contrast medium was clear that it was short-segment stenosis, endoscopic stenosis incision was performed, and the active longitudinal ulcer at the lateral end of the anastomosis was found. The drug was decisively changed, combined with endoscopic intervention, and re-operation was avoided.

A 28-year-old male with onset of acute disorder of consciousness was transferred to Xuanwu Hospital after magnetic resonance revealed acute multiple cerebral infarction in another hospital. After a series of stroke vascular risk factors, autoimmunity, cardiovascular and cardiac rhythm and structure, lower extremity arteriovenous screening, it was found that it was anti-β 2 glycoprotein I (A β 2GPI) antibody positive antiphospholipid syndrome (APS) and patent foramen ovale (PFO) coexisted. Through differential analysis, arterial thromboembolism secondary to hypercoagulable state of APS was prioritized as the cause of this stroke. After treatment with aspirin and hydroxychloroquine, no vascular events occurred, and the A β 2GPI antibody turned negative at 14 months of follow-up. It is suggested that antiplatelet therapy may be effective for secondary prevention of arterial thrombotic/embolic events caused by APS, and hydroxychloroquine may play a role in reducing antibody titer to some extent.

As one of the main ischemic stroke subtypes in clinic, cryptogenic stroke has complex and diverse causes, including paroxysmal atrial fibrillation, atrial heart disease, patent foramen ovale, carotid web, non-stenotic atherosclerosis and cancer. Diseases such as cancer need to be evaluated in detail and targeted, and the risk of recurrence needs to be highly valued. The concept of embolic stroke of unknown origin (ESUS) makes it a treatment-related disease. Antiplatelet, anticoagulant, interventional and surgical treatments should be used for different etiologies to reduce the recurrence rate of stroke.

Statins can improve the survival rate of patients with atherosclerotic stroke and have pleiotropic benefits such as anticancer, anti-inflammatory, antioxidant, anti-proliferative and plaque stabilization in addition to lipid lowering. Among them, anti-cancer effects are mainly through anti-proliferation, pro-apoptosis, migration and inhibition of invasion. However, it is unclear whether statins provide additional survival benefits for stroke patients with a history of cancer.

The mortality and disability rate of acute basilar artery occlusion are high with simple drug therapy, but the efficacy and safety of thrombectomy for this part of patients always lack high-level evidence-based evidence to support. The purpose of this study was to evaluate the efficacy and safety of endovascular mechanical thrombectomy in patients with acute basilar artery occlusion within 6 to 24 hours of onset.