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We found that early positive troponin after ischemic stroke may be independently associated with a cardiac embolic source. Future studies are needed to confirm our findings using high-sensitivity troponin assays and to test optimal secondary prevention strategies in patients with embolic stroke of unknown source and positive troponin.

There is evidence suggesting that Los Angeles Motor Scale (LAMS) ࣙ 4 predicts large vessel occlusion (LVO). We aim to determine whether atrial fibrillation (AF) can improve the ability of LAMS in predicting LVO. METHODS: We included consecutive patients with a discharge diagnosis of ischemic stroke admitted within 24 hours from last known normal time who underwent emergent vascular imaging using a computerized tomography angiography (CTA) of the head and neck. LVO was defined as intracranial internal carotid artery, proximal middle cerebral artery (M1 or proximal M2 segment), or basilar occlusion. LAMS was determined in the emergency department upon arrival. Univariate and multivariable models were performed to identify predictors of LVO and to determine whether AF improves the ability of LAMS to predict LVO. RESULTS:Among 1,234 patients admitted with ischemic stroke, 862 underwent emergent vascular imaging (69.8%) out of which 374 (43.4%) had evidence of LVO and 207 (24%) underwent mechanical thrombectomy. In multivariable models, predictors of LVO were LAMS (OR 1.42 per one point increase 95% CI 1.29-1.57) and AF (OR 1.95 95% CI 1.26-3.02, P < .001). We developed the LAMS-AF that includes the LAMS score and adds two points if AF is present. In this analysis, LAMS-AF (AUC .78) had improved prediction over LAMS (AUC .76) in predicting LVO and lead to reclassification of 8/68 patients (11.8%) with LAMS = 3 group into the high-risk LVO group. CONCLUSION: In patients with LAMS = 3, using the LAMS-AF score may improve the ability of LAMS in predicting LVO. Larger studies are needed to confirm our findings.

We present the case of a 71 y/o man with chronic obstructive pulmonary disease (COPD) who presented with 3 weeks of cough, phlegm, fever, and failed outpatient antibiotic therapy for pneumonia. CT of the chest showed unilateral interstitial changes and bronchoscopic biopsies demonstrated primary lung papillary adenocarcinoma and extensive concentric psammomatous calcifications.

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Background and Purpose-Transthoracic echocardiography (TTE) is widely used in the ischemic stroke setting. In this study, we aim to investigate the yield of TTE in patients with ischemic stroke and known subtype and whether the admission troponin level improves the yield of TTE.Methods-Data was abstracted from a single center prospective ischemic stroke database over 18 months and included all patients with ischemic stroke whose etiologic subtype could be obtained without the need of TTE. Unadjusted and adjusted regression models were built to determine whether positive cardiac troponin levels (≥ 0.1 ng/mL) improve the yield of TTE, adjusting for demographic and clinical.Results-We identified 578 patients who met the inclusion criteria. TTE changed clinical management in 64 patients (11.1%) but intracardiac thrombus was detected in only 4 patients (0.7%). In multivariable models, there was an association between TTE changing management and positive serum troponin level (adjusted OR 4.26; 95% CI 2.17-8.34; p<0.001). Conclusion-In ischemic stroke patients, TTE might lead to a change in clinical management in nearly one out of ten patients with known stroke subtype prior to TTE but changed acute treatment decisions in less than one percent of patients. Serum troponin levels improved the yield of TTE in these patients.

A young man with a history of smoking presented with acute-onset chest pain after lifting weights. He also noticed a change in his voice, tightness in his neck and difficulty breathing. A chest radiograph showed soft tissue emphysema in the neck. A CT scan of the chest revealed moderate amount of pneumomediastinum tracking into the neck and down to the diaphragm. He was haemodynamically stable and had no hypoxia or dysphagia. He was monitored for 48 hours and discharged home after resolution of his symptoms. A chest radiograph repeated after 6 weeks was normal.