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Shows chest X-rays of the patient. (A) Taken after clinical deterioration showing features of ARDS (bilateral lung in fi ltrates); (B) X-ray which was taken seven days after instituting treatment showing clearing of lung in fi ltrates.
Source publication
Pneumonia due to H1N1 infection is now very common. We report a case of ischemic stroke which arose subsequently to H1N1 influenza. The patient was a female who developed acute respiratory distress syndrome (ARDS) after H1N1 influenza, was ventilated as per standard protocol and started treatment with oseltamivir. When sedation was stopped during w...
Contexts in source publication
Context 1
... condition suddenly deteriorated (SpO 2 dropped to 75% and respiratory rate increased to 50/min); her trachea was thus intubated and invasive ventilation was instituted (Tables 1,4). Her C-reactive protein (CRP) was high (Tables 2,3). She was found to have developed acute respiratory distress syndrome (ARDS) as a complication of H1N1 pneumonia (Fig. 1A). She was then treated as per net ARDS protocol and sedated with morphine 3e5 mg/hour and midazolam 3e6 mg/ hour infusions, in accordance with our institute's protocol for ARDS patients. No muscle relaxant was necessary throughout the period of invasive ventilation. Her respiratory condition and radiographic picture improved (Fig. 1B) ...
Context 2
... pneumonia (Fig. 1A). She was then treated as per net ARDS protocol and sedated with morphine 3e5 mg/hour and midazolam 3e6 mg/ hour infusions, in accordance with our institute's protocol for ARDS patients. No muscle relaxant was necessary throughout the period of invasive ventilation. Her respiratory condition and radiographic picture improved (Fig. 1B) after 7 days of mechanical ventilation and thus, the weaning process was started. Sedatives were stopped and over the next 2 days she could tolerate minimal ventilator support. However, we did not venture to extubate her, as she was not waking up (even though she could respond to pain). On neurological evaluation, she was found to ...
Citations
... ARDS can be associated with secondary brain injury, which may further impact survival and functional outcome [7][8][9]. Hypoxic-ischemic brain injury, cerebral microbleeds (CMBs), and ischemic and hemorrhagic strokes have been reported in patients with ARDS [7,[10][11][12]. The mechanism of ARDS-associated brain injury is not well understood but is thought to be in part related to the lung and brain crosstalk, in which diffuse pulmonary injury may lead to systemic release of inflammatory markers causing cerebral dysfunction [13][14][15][16][17][18]. ...
Background
Acute respiratory distress syndrome (ARDS) is an acute inflammatory respiratory failure condition that may be associated with brain injury. We aimed to describe the types of structural brain injuries detected by brain magnetic resonance imaging (MRI) among patients with ARDS.Methods
We retrospectively reviewed and collected data on brain injuries as detected by brain MRI during index hospitalization of all patients with ARDS at a single tertiary center in the United States from January 2010 to October 2018 (pre-COVID era). Structural brain injuries were classified as cerebral ischemia (ischemic infarct and hypoxic-ischemic brain injury) or cerebral hemorrhage (intraparenchymal hemorrhage, cerebral microbleeds, subarachnoid hemorrhage, and subdural hematoma). Descriptive statistics were conducted.ResultsOf the 678 patients with ARDS, 66 (9.7%) underwent brain MRI during their ARDS illness. The most common indication for brain MRI was encephalopathy (45.4%), and the median time from hospital admission to MRI was 10 days (interquartile range 4–17). Of 66 patients, 29 (44%) had MRI evidence of brain injury, including cerebral ischemia in 33% (22 of 66) and cerebral hemorrhage in 21% (14 of 66). Among those with cerebral ischemia, common findings were bilateral globus pallidus infarcts (n = 7, 32%), multifocal infarcts (n = 5, 23%), and diffuse hypoxic-ischemic brain injury (n = 3, 14%). Of those with cerebral hemorrhage, common findings were cerebral microbleeds (n = 12, 86%) and intraparenchymal hemorrhage (n = 2, 14%). Patients with ARDS with cerebral hemorrhage had significantly greater use of rescue therapies, including prone positioning (28.6% vs. 5.8%, p = 0.03), inhaled vasodilator (35.7% vs. 11.5%, p = 0.046), and recruitment maneuver (14.3% vs. 0%, p = 0.04).Conclusions
Structural brain injury was not uncommon among selected patients with ARDS who underwent brain MRI. The majority of brain injuries seen were bilateral globus pallidus infarcts and cerebral microbleeds.
... ARDS can be associated with secondary acute brain injury (ABI), which may further impact survival and functional outcome (7)(8)(9). Hypoxic ischemic brain injury (HIBI), cerebral microbleeds (CMBs), and ischemic and hemorrhagic strokes have been reported in ARDS patients (7,(10)(11)(12). The mechanism of ARDS associated ABI is thought to be related to the lung and brain crosstalk where diffuse pulmonary injury may lead to systemic release of in ammatory markers causing cerebral dysfunction (13)(14)(15)(16)(17)(18). ...
Objective: Acute Respiratory Distress Syndrome(ARDS) is an acute inflammatory respiratory failure condition that may be associated with acute brain injury (ABI). We aimed to describe the prevalence and types of ABI detected by brain MRI among ARDS patients.
Methods: We retrospectively reviewed and collected data on ABI as detected by brain MRI during index hospitalization of all ARDS patients at a single tertiary center in the United States from January 2010 to October 2018. ABIs were classified as cerebral ischemia (ischemic infarct and hypoxic ischemic brain injury) or cerebral hemorrhage (intraparenchymal hemorrhage, cerebral microbleeds, subarachnoid hemorrhage, and subdural hematoma). Descriptive statistics were conducted.
Results: Of the 678 ARDS patients, 66 (9.7%) underwent brain MRI during their ARDS illness. The most common indication for brain MRI was encephalopathy (45.4%) and the median time from hospital admission to MRI was 10 days (interquartile range 4-17). Of 66, 29 (44%) had MRI evidence of ABI including cerebral ischemia in 33% (22/66) and cerebral hemorrhage in 21% (14/66). Among those with cerebral ischemia, common findings were bilateral globus pallidus infarcts (n=7, 32%), multifocal infarcts (n=5, 23%), and diffuse hypoxic ischemic brain injury (n=3, 14%). Of those with cerebral hemorrhage, common findings were cerebral microbleeds (n=12, 86%) and intraparenchymal hemorrhage (n=2, 14%). ARDS patients with cerebral hemorrhage had significantly greater use of rescue therapies including prone positioning (28.6% vs 5.8%, p = 0.03), inhaled vasodilator (35.7% vs 11.5%, p = 0.046), and recruitment maneuver (14.3% vs 0%, p = 0.04).
Conclusion: Among selected patients with ARDS who underwent brain MRI, almost a half had ABI most commonly including bilateral globus pallidus infarcts and cerebral microbleeds.
... Several symptoms necessitated hospitalization. There were 18/58 (31.3%) of the patients who had flu-like symptoms but no respiratory failure [28,31,34,35,[37][38][39]43,44,[46][47][48][49], 31/58 of the patients (53.4%) with respiratory failure [9,[24][25][26][27]29,30,[32][33][34]40,51], 15/58 (25.8%) with neurological symptoms [25,28,30,31,35,37,38,[42][43][44][46][47][48][49][50] our case, and 5/58 (8.6%) with gastrointestinal symptoms [36,39,41,45,48]. Two patients with neurological onset reported vision loss-one due to vaso-occlusive vasculitis [48] and the other to a combined retinal and lateral geniculate nucleus infarction [49]; the onset was not described in 18/58 (31.3%) of the remaining cases. ...
... Several symptoms necessitated hospitalization. There were 18/58 (31.3%) of the patients who had flu-like symptoms but no respiratory failure [28,31,34,35,[37][38][39]43,44,[46][47][48][49], 31/58 of the patients (53.4%) with respiratory failure [9,[24][25][26][27]29,30,[32][33][34]40,51], 15/58 (25.8%) with neurological symptoms [25,28,30,31,35,37,38,[42][43][44][46][47][48][49][50] our case, and 5/58 (8.6%) with gastrointestinal symptoms [36,39,41,45,48]. Two patients with neurological onset reported vision loss-one due to vaso-occlusive vasculitis [48] and the other to a combined retinal and lateral geniculate nucleus infarction [49]; the onset was not described in 18/58 (31.3%) of the remaining cases. ...
... A complicating bacterial pneumonia was diagnosed in 4/58 of the patients (6.9%) [29,33,35,44]. A radiological picture of ARDS was found in 14 of the 58 (24.1%) patients [25,26,28,30], whereas in 28/58 (48.2%) of the cases, chest X-rays or chest CT scans were not reported or not performed. Most patients had a radiological picture consistent with viral pneumonia; however, in four cases, the chest CT revealed reticulonodular infiltrates or extensive bilateral densities in the absence of a positive sputum culture [23,35,51] our case. ...
Introduction:
Influenza is an acute respiratory infection that usually causes a short-term and self-limiting illness. However, in high-risk populations, this can lead to several complications, with an increase in mortality. Aside from the well-known extrapulmonary complications, several studies have investigated the relationship between influenza and acute cardio and cerebrovascular events. Reviews of the thromboembolic complications associated with influenza are lacking.
Objectives:
the study aims to conduct a scoping review to analyze the epidemiological and clinical characteristics of patients suffering from influenza and thromboembolic complications.
Materials and methods:
A computerized search of historical published cases using PubMed and the terms "influenza" or "flu" and "thrombosis", "embolism", "thromboembolism", "stroke", or "infarct" for the last twenty-five years was conducted. Only articles reporting detailed data on patients with thromboembolic complications of laboratory-confirmed influenza were considered eligible for inclusion in the scoping review.
Results:
Fifty-eight cases with laboratory documented influenza A or B and a related intravascular thrombosis were retrieved. Their characteristics were analyzed along with those of a patient who motivated our search. The localizations of thromboembolic events were pulmonary embolism 21/58 (36.2%), DVT 12/58 (20.6%), DVT and pulmonary embolism 3/58 (5.1%), acute ischemic stroke 11/58 (18.9%), arterial thrombosis 4/58 (6.8%), and acute myocardial infarction 5/58 (8.6%).
Discussion:
Our findings are important in clarifying which thromboembolic complications are more frequent in adults and children with influenza. Symptoms of pulmonary embolism and influenza can be very similar, so a careful clinical evaluation is required for proper patient management, possible instrumental deepening, and appropriate pharmacological interventions, especially for patients with respiratory failure.
... Its pathophysiologic mechanisms include activation of the endothelial cells and systemic inflammation, which result to subsequent activation of the coagulation system and to thrombi formation. Increased risk of ischaemic stroke is additionally associated to reactive oxygen radicals due to acute lung injury and hypoxemia [89], while prolonged hypoxemia in patients with severe respiratory failure leads to reduced delivery of oxygen and glucose to the brain. As a consequence mitochondrial dysfunction and upregulation of energy-dependent ion chains are manifested, causing neuronal apoptosis, necrosis, and cytotoxic oedema [5,6]. ...
A complex interrelation between lung and brain in patients with acute lung injury (ALI) has been established by experimental and clinical studies during the last decades. Although, acute brain injury represents one of the most common insufficiencies in patients with ALI and acute respiratory distress syndrome (ARDS), the underlying pathophysiology of the observed crosstalk remains poorly understood due to its complexity. Specifically, it involves numerous pathophysiological parameters such as hypoxemia, neurological adverse events of lung protective ventilation, hypotension, disruption of the BBB, and neuroinflammation in such a manner that the brain of ARDS patients—especially hippocampus—becomes very vulnerable to develop secondary lung-mediated acute brain injury. A protective ventilator strategy could reduce or even minimize further systemic release of inflammatory mediators and thus maintain brain homeostasis. On the other hand, mechanical ventilation with low tidal volumes may lead to self-inflicted lung injury, hypercapnia and subsequent cerebral vasodilatation, increased cerebral blood flow, and intracranial hypertension. Therefore, by describing the pathophysiology of ARDS-associated acute brain injury we aim to highlight and discuss the possible influence of mechanical ventilation on ALI-associated acute brain injury.
... Neurological involvement has been associated with H1N1 infection though sparsely reported. 3,4 Acute viremia itself can lead to altered sensorium in addition to pronounced hypoxemia in cases of severe pulmonary involvement. Various cytokines are released which cause a myriad of changes in the patient. ...
Influenza has a common occurrence during its peak seasons. It usually causes disease of the
respiratory tract including severe acute respiratory distress syndrome. However, it may also cause disease and complication of other organ systems. We present a rare complication of influenza in which a patient secondary to influenza developed massive middle cerebral artery ischemic stroke. The patient however survived following recovery of both severe acute respiratory distress syndrome and ischemic stroke after decompressive craniectomy and a prolonged intensive care unit stay. This case report is to highlight the importance of influenza related complications besides the pulmonary infliction which can lead to morbidity and even mortality if not managed on time.
... Exercises were mainly based on the Proprioceptive Neuromuscular Facilitation (PNF) concept to support overall physical fitness, as well as to increase chest mobility and improve breathing efficiency (Figure 7). Exercise supported the mechanism of opening collapsed alveoli and removing excess secretions from the patient's airways [16,17]. Due to the individual needs of the patients and their complaints, the techniques described in Table 3 were performed in addition to the breathing exercises [13]. ...
... Ischemic brain injury was also commonly observed in ARDS. The mechanisms of ischemic stroke included watershed infarcts in the setting of septic shock and gas emboli secondary to barotrauma from mechanical ventilation [33,54]. An autopsy study on patients with ARDS showed that HIBI was most commonly observed in hippocampus, specifically the pyramidal neurons in the CA1 region [33]. ...
Acute respiratory distress syndrome (ARDS) has been associated with secondary acute brain injury (ABI). However, there is sparse literature on the mechanism of lung-mediated brain injury and prevalence of ARDS-associated secondary ABI. We aimed to review and elucidate potential mechanisms of ARDS-mediated ABI from preclinical models and assess the prevalence of ABI and neurological outcome in ARDS with clinical studies. We conducted a systematic search of PubMed and five other databases reporting ABI and ARDS through July 6, 2020 and included studies with ABI and neurological outcome occurring after ARDS. We found 38 studies (10 preclinical studies with 143 animals; 28 clinical studies with 1175 patients) encompassing 9 animal studies (n = 143), 1 in vitro study, 12 studies on neurocognitive outcomes (n = 797), 2 clinical observational studies (n = 126), 1 neuroimaging study (n = 15), and 13 clinical case series/reports (n = 15). Six ARDS animal studies demonstrated evidence of neuroinflammation and neuronal damage within the hippocampus. Five animal studies demonstrated altered cerebral blood flow and increased intracranial pressure with the use of lung-protective mechanical ventilation. High frequency of ARDS-associated secondary ABI or poor neurological outcome was observed ranging 82–86% in clinical observational studies. Of the clinically reported ABIs (median age 49 years, 46% men), the most common injury was hemorrhagic stroke (25%), followed by hypoxic ischemic brain injury (22%), diffuse cerebral edema (11%), and ischemic stroke (8%). Cognitive impairment in patients with ARDS (n = 797) was observed in 87% (range 73–100%) at discharge, 36% (range 32–37%) at 6 months, and 30% (range 25–45%) at 1 year. Mechanisms of ARDS-associated secondary ABI include primary hypoxic ischemic injury from hypoxic respiratory failure, secondary injury, such as lung injury induced neuroinflammation, and increased intracranial pressure from ARDS lung-protective mechanical ventilation strategy. In summary, paucity of clinical data exists on the prevalence of ABI in patients with ARDS. Hemorrhagic stroke and hypoxic ischemic brain injury were commonly observed. Persistent cognitive impairment was highly prevalent in patients with ARDS.
... These apparently disparate diseases share physiological and clinical associations. Burad et al. (2012) found that acute respiratory syndrome in pneumonia patients leads to strong systemic ischemia that may in turn develop into acute encephalopathy. This finding has been further confirmed in a very large (5.6 million cases) epidemiological risk factor study of the group of Bell in the US (Rincon et al., 2014). ...
Background: Cardiovascular diseases are the leading causes of mortality worldwide. One reason behind this lethality lies in the fact that often cardiovascular illnesses develop into systemic failure due to the multiple connections to organismal metabolism. This in turn is associated with co-morbidities and multimorbidity. The prevalence of coexisting diseases and the relationship between the molecular origins adds to the complexity of the management of cardiovascular diseases and thus requires a profound knowledge of the genetic interaction of diseases.
Objective: In order to develop a deeper understanding of this phenomenon, we examined the patterns of comorbidity as well as their genetic interaction of the diseases (or the lack of evidence of it) in a large set of cases diagnosed with cardiovascular conditions at the national reference hospital for cardiovascular diseases in Mexico.
Methods: We performed a cross-sectional study of the National Institute of Cardiology. Socioeconomic information, principal diagnosis that led to the hospitalization and other conditions identified by an ICD-10 code were obtained for 34,099 discharged cases. With this information a cardiovascular comorbidity networks were built both for the full database and for ten 10-years age brackets. The associated cardiovascular comorbidities modules were found. Data mining was performed in the comprehensive ClinVar database with the disease names (as extracted from ICD-10 codes) to establish (when possible) connections between the genetic associations of the genetic interaction of diseases. The rationale is that some comorbidities may have a stronger genetic origin, whereas for others, the environment and other factors may be stronger.
Results: We found that comorbidity networks are highly centralized in prevalent diseases, such as cardiac arrhythmias, heart failure, chronic kidney disease, hypertension, and ischemic diseases. Said comorbidity networks are actually modular on their connectivity. Modules recapitulate physiopathological commonalities, e.g., ischemic diseases clustering together. This is also the case of chronic systemic diseases, of congenital malformations and others. The genetic and environmental commonalities behind some of the relations in these modules were also found by resorting to clinical genetics databases and functional pathway enrichment studies.
Conclusions: This methodology, hence may allow the clinician to look up for non-evident comorbidities whose knowledge will lead to improve therapeutically designs. By continued and consistent analysis of these types of patterns, we envisaged that it may be possible to acquire, strong clinical and basic insights that may further our advance toward a better understanding of cardiovascular diseases as a whole. Hopefully these may in turn lead to further development of better, integrated therapeutic strategies.
... Transient ischemia in the brain occurs when the blood supply to part of the brain or the whole brain is briefly interrupted by occlusion of regional arteries or by cardiac ischemia [1,2]. Transient brain ischemia results in irreversible and persistent damage to the brain parenchyma [3,4]. ...
Laminarin is a polysaccharide isolated from brown algae that has various biological and pharmacological activities, such as antioxidant and anti-inflammatory properties. We recently reported that pretreated laminarin exerted neuroprotection against transient forebrain ischemia/reperfusion (IR) injury when we pretreated with 50 mg/kg of laminarin once a day for seven days in adult gerbils. However, there have been no studies regarding a neuroprotective effect of pretreated laminarin against IR injury in aged animals and its related mechanisms. Therefore, in this study, we intraperitoneally inject laminarin (50 mg/kg) once a day to aged gerbils for seven days before IR (5-min transient ischemia) surgery and examine the neuroprotective effect of laminarin treatment and the mechanisms in the gerbil hippocampus. IR injury in vehicle-treated gerbils causes loss (death) of pyramidal neurons in the hippocampal CA1 field at five days post-IR. Pretreatment with laminarin effectively protects the CA1 pyramidal neurons from IR injury. Regarding the laminarin-treated gerbils, production of superoxide anions, 4-hydroxy-2-nonenal expression and pro-inflammatory cytokines [interleukin(IL)-1β and tumor necrosis factor-α] expressions are significantly decreased in the CA1 pyramidal neurons after IR. Additionally, laminarin treatment significantly increases expressions of superoxide dismutase and anti-inflammatory cytokines (IL-4 and IL-13) in the CA1 pyramidal neurons before and after IR. Taken together, these findings indicate that laminarin can protect neurons from ischemic brain injury in an aged population by attenuating IR-induced oxidative stress and neuroinflammation.
... One case of multiple strokes occurred in a young woman with disseminated intravascular coagulation (DIC) who was critically ill [72]. The other case occurred in a 50 year old woman with ARDS secondary to influenza A(H1N1) who developed multiple strokes in the territory of the right middle cerebral artery [73]. There may be indirect evidence of an association between influenza and CVAs but data from influenza vaccination and neuraminidase inhibitors are conflicting [74,75]. ...
Severe influenza infection represents a leading cause of global morbidity and mortality. Although influenza is primarily considered a viral infection that results in pathology limited to the respiratory system, clinical reports suggest that influenza infection is frequently associated with a number of clinical syndromes that involve organ systems outside the respiratory tract. A comprehensive Medline literature review of articles pertaining to extra-pulmonary complications of influenza infection, using organ-specific search terms, yielded 234 articles including case reports, epidemiologic investigations, and autopsy studies that were reviewed to determine the clinical involvement of other organs. The most frequently described clinical entities were viral myocarditis and viral encephalitis. Recognition of these extra-pulmonary complications is critical to determining the true burden of influenza infection and initiating organ-specific supportive care. This article is protected by copyright. All rights reserved.
