RESUMO
BACKGROUND: For patients with acute vessel occlusions of the anterior circulation histopathology of retrieved cerebral thrombi has been reported to be associated to stroke etiology. Due to the relatively small incidence of posterior circulation stroke, exclusive histopathologic analyses are missing for this subgroup. The aim of the study was to investigate thrombus histology for patients with basilar artery occlusions and uncover differences to anterior circulation clots with respect to underlying etiology. METHODS: A total of 59 basilar thrombi were collected during intracranial mechanical recanalization and quantitatively analyzed in terms of their relative fractions of the main constituents, e.g. fibrin/platelets (F/P), red (RBC) and white blood cells (WBC). Data were compared to histopathological analyses of 122 thrombi of the anterior circulation with respect to underlying pathogenesis. RESULTS: The composition of basilar thrombi differed significantly to thrombi of the anterior circulation with an overall higher RBC amount (median fraction in % (interquartile range):0.48 (0.37-0.69) vs. 0.37 (0.28-0.50), pâ¯< 0.001) and lower F/P count (0.45 (0.21-0.58) vs. 0.57 (0.44-0.66), pâ¯< 0.001). Basilar thrombi composition did not differ between the different etiological stroke subgroups. CONCLUSION: The results depict a differing thrombus composition of basilar thrombi in comparison to anterior circulation clots with an overall higher amount of RBC. This may reflect different pathophysiologic processes between anterior and posterior circulation thrombogenesis, e.g. a larger proportion of appositional thrombus growth in the posterior circulation.
Assuntos
Acidente Vascular Cerebral , Trombose , Artéria Basilar/diagnóstico por imagem , Eritrócitos , Humanos , Trombectomia , Trombose/diagnóstico por imagemRESUMO
In 2007, the first poll among neurologists provided some insight into the organizational structures of emergency neurology in Germany. Given that emergency neurology as well as emergency medicine in general have undergone substantial changes during the last decade, the subcommittee Neurological Emergency Medicine of the German Neurological Society conducted a follow-up study to explore current structures supporting neurological emergency medicine in German neurological hospitals. Between July and September 2016, an online questionnaire was emailed to 675 neurologists in institutions participating in in-patient neurological care. Of these, some 32% (university hospitals 49%) answered. Neurological patients represent 12-16% and hence a significant proportion of emergency patients. The fraction of in-patients admitted to hospitals via emergency departments amounted to 78% (median) in general hospitals and 52% in university hospitals. Most emergency departments are organized as an interdisciplinary structure combining conservative with surgical disciplines frequently led by an independent department head. Neurology departments employ rather diverse strategies to organize neurological emergency care. Also, the way emergency patients are assigned to different disciplines varied largely. Currently, neurological patients represent a rather growing fraction of patients in emergency departments. An increasing proportion of neurology in-patients enter the hospital via emergency departments. Neurology departments in Germany face increasing challenges to cope with large numbers of neurological emergency patients. While most of the participating neurologists indicated suffering predominantly from scarce personal resources both in neurology and neuroradiology, an independent neurological emergency department was not considered an option.
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Medicina de Emergência/organização & administração , Serviço Hospitalar de Emergência/organização & administração , Hospitais Gerais/organização & administração , Internet/estatística & dados numéricos , Modelos Organizacionais , Neurologistas/organização & administração , Neurologia/organização & administração , Atenção à Saúde/organização & administração , Alemanha , Pesquisas sobre Atenção à SaúdeRESUMO
BACKGROUND AND PURPOSE: Periprocedural thrombus fragmentation is a relevant risk in endovascular stroke treatment. Because factors influencing its occurrence are largely unknown, this study addresses a potential relationship between thrombus histology and clot stability. MATERIALS AND METHODS: Eighty-five patients with anterior circulation stroke treated with thrombectomy were included in this retrospective study. The number and location of emboli after retrieving the primary thrombus, the number of maneuvers, and TICI scores were evaluated. H&E and neutrophil elastase staining of retrieved clots was performed, and semiquantitative measurements of thrombus components were correlated with procedural parameters. RESULTS: An inverse correlation between maneuvers required for thrombus retrieval and the number of distal and intermediate emboli was observed (Spearman r, -0.23; P = .032). Younger patients were at higher risk for periprocedural thrombus fragmentation (Spearman r, -0.23; P = .032). Bridging thrombolysis tended to be associated with fewer maneuvers (2 vs 3, P = .054) but more emboli (1 vs 0, P = .067). While no consistent correlation between procedural parameters and red/white blood cells and fibrin-/platelet fractions could be found, higher amounts of neutrophil elastase-positive cells within the thrombus were independently associated with the occurrence of multiple emboli (adjusted OR, 4.6; 95% CI, 1.1-19.7; P = .041) and lower rates of complete recanalization (adjusted OR, 0.3; 95% CI, 0.1-0.9; P = .050). CONCLUSIONS: Younger age, easy-to-retrieve thrombi, and bridging thrombolysis may be risk factors for periprocedural thrombus fragmentation. Findings from standard histologic stains did not provide insight into thrombectomy-relevant thrombus stability. However, higher neutrophil levels in the thrombus tissue were related to an increased risk of periprocedural thrombus fragmentation. This observation aligns with the proposed thrombolytic capacity of neutrophil elastase and points to its potential clinical relevance in the context of stroke thrombectomy.
Assuntos
Embolia/etiologia , Procedimentos Endovasculares/efeitos adversos , Acidente Vascular Cerebral/cirurgia , Trombectomia/efeitos adversos , Idoso , Feminino , Humanos , Trombose Intracraniana/cirurgia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
PURPOSE: Thrombus composition has been suggested to have a decisive impact on the outcome of patients treated by mechanical thrombectomy because of embolic stroke. The recent development of stent retrievers allows collection and, hence, histopathological analysis of fresh thrombus material. Against this background, the aim of this prospective study was to assess the impact of thrombus composition on mechanical recanalization, clinical outcome and stroke etiology. METHODS: Thirty-four patients suffering from acute ischemic stroke due to occlusion of the distal internal carotid artery/carotid-T, anterior cerebral artery, or middle cerebral arteries were mechanically recanalized, and thrombus material was obtained. Histological thrombus composition was compared with imaging, clinical, and neurointerventional data. RESULTS: The main findings were that a higher percentage of white blood cells (WBCs) in the thrombus was associated with (i) cardioembolic etiology, (ii) extended mechanical recanalization time, and (iii) less favorable recanalization (Thrombolysis in Cerebral Infarction score) and clinical outcome (National Institute of Health Stroke Scale). CONCLUSION: Our results suggest that thrombi with a high WBC fraction are related to more organized thrombi of cardioembolic origin associated with less favorable recanalization and clinical outcome in acute ischemic anterior circulation stroke. WBC-mediated immunological and coagulatory processes may play a key role in thrombus formation and pathogenesis of stroke warranting further investigation.
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Embolia Intracraniana/patologia , Embolia Intracraniana/terapia , Leucócitos/patologia , Trombólise Mecânica , Acidente Vascular Cerebral/patologia , Acidente Vascular Cerebral/terapia , Trombose/patologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Embolia Intracraniana/complicações , Contagem de Leucócitos , Masculino , Pessoa de Meia-Idade , Acidente Vascular Cerebral/etiologia , Resultado do Tratamento , Adulto JovemRESUMO
PURPOSE: The purpose of this study was to analyze the safety and efficacy of the pREset device, a stent retriever system, for endovascular mechanical thrombectomy (MT) in acute ischemic stroke (AIS) after middle cerebral artery (MCA) occlusion. METHODS: Retrospectively, 48 consecutive patients (mean age ± standard deviation, 71.0 ± 11.9 years; 24 women) treated for acute MCA occlusion using pREset solely or in combination with other MT devices were identified. Recanalization success was evaluated using the modified thrombolysis in cerebral infarction score (TICI), and complications were detected by 24-h follow-up computed tomography or magnetic resonance imaging. MCA anatomy was assessed in angiograms. Clinical outcome was evaluated with National Institutes of Health Stroke Scale (NIHSS) score at admission and discharge, and modified Rankin scale (mRS) score at discharge and follow-up. RESULTS: Successful recanalization (TICI 2b/3) was achieved in 39 patients (81.3 %). Rate of procedure-related complications was 8.3 %. In four patients, a subarachnoid hemorrhage occurred (8.3 %), and parenchymal hematoma was detected in four patients (8.3 %). None of those events was associated with clinical deterioration. MCA curvature significantly influenced recanalization success (P < 0.005). Successful recanalization correlated significantly with lower NIHSS scores and favorable clinical outcome (mRS score 0-2) at discharge (P < 0.05). Mortality within 90 days was significantly lower in patients with TICI 2b/3 (P < 0.005). CONCLUSIONS: High recanalization rates, low complication rates, and a significantly improved outcome after successful recanalization strongly suggest that MT with pREset is an adequate therapy for AIS after MCA occlusion. Vessel curvature is a significant determining factor for recanalization success.
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Hemorragia Cerebral/etiologia , Infarto da Artéria Cerebral Média/cirurgia , Trombólise Mecânica/efeitos adversos , Trombólise Mecânica/instrumentação , Acidente Vascular Cerebral/cirurgia , Idoso , Angiografia Cerebral , Hemorragia Cerebral/prevenção & controle , Desenho de Equipamento , Análise de Falha de Equipamento , Feminino , Humanos , Infarto da Artéria Cerebral Média/complicações , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Masculino , Stents/efeitos adversos , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/etiologia , Resultado do TratamentoRESUMO
BACKGROUND AND PURPOSE: Intravenous thrombolysis with rtPA is the standard of care for patients with acute ischemic stroke within 4.5 hours after symptom onset. However, a considerable number of patients are ineligible for IV thrombolysis due to various contraindications. Recent studies have proved the superiority of mechanical thrombectomy for patients with large-vessel occlusions in combination with IV rtPA compared with IV rtPA alone. We aimed to demonstrate the efficacy of mechanical thrombectomy for patients who are ineligible for IV rtPA. MATERIALS AND METHODS: Patients from the stroke registries of 4 dedicated centers who were treated with mechanical thrombectomy from January 2010 to October 2014 were retrospectively evaluated. Inclusion criteria were the following: acute stroke due to proved large-artery occlusion, ineligibility for IV thrombolysis, and a timeframe of ≤4.5 hours between stroke and the start of mechanical thrombectomy. Recanalization success, periprocedural complications, clinical outcome, and hemorrhages were evaluated. RESULTS: One hundred thirty endovascular recanalization procedures were identified. The locations were the following: proximal ICA in 17 (13.1%), terminus ICA in 25 (19.2%), M1 segment in 77 (59.2%), and M2 segment in 11 (8.5%). TICI 2b/3 results were achieved in 101 (77.7%), and an mRS score of 0-2 in 47 patients (37.9%). There was a significant correlation between TICI 2b/3 results and good clinical outcomes (87.2% versus 6.8%; P = .048). A good clinical result was most frequent when recanalization was achieved within 4.5 hours (37/74 = 50% versus 10/50 = 20.0%; P = .001). Symptomatic hemorrhage occurred in 13.1% of patients; mortality was 24.2%. Periprocedural complications were recorded in 10 patients (7.7%). CONCLUSIONS: Mechanical thrombectomy can achieve good clinical outcomes in patients with acute large-artery occlusion ineligible for IV thrombolysis, in particular when recanalization is reached early.
Assuntos
Acidente Vascular Cerebral/terapia , Trombectomia/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Stents , Resultado do TratamentoRESUMO
BACKGROUND: Despite important advances in therapeutic approaches in stroke, the options of acute treatment are still limited. Primary prevention represents another potentially highly efficient strategy. For effective prevention the early detection of subjects at risk is of utmost importance. Coinciding with a change in current understanding of atherosclerosis as an inflammatory, cross-organ disease, new parameters to assess the individual risk are emerging. METHODS: Systematic review of the potential of selected parameters for prediction of cerebrovascular events beyond detection of traditional risk factors that might expand the repertoire of primary prevention programs in stroke. RESULTS: An absolute carotid intima-media thickness difference of 0.1 mm increases the future risk of stroke by 13-18%. An ankle-brachial index <0.9 was associated with a relative risk of 2.33 (95% CI 2.02-2.68) for stroke. In patients with acute stroke and ABI values < 0.9 the risk for a new vascular event is significantly increased (HR 2.1; 95% CI 1.6-2.8). Measurements of several molecular biomarkers may be used to predict future vascular events independently of traditional risk factors. CONCLUSIONS: Based on the data presented, there is clear evidence that measurement of the ankle-brachial index identifies subjects of increased stroke risk in primary and secondary care settings as well as of stroke recurrence in acute stroke.
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Índice Tornozelo-Braço , Inflamação/metabolismo , Acidente Vascular Cerebral/diagnóstico , Túnica Íntima/patologia , Túnica Média/patologia , 1-Alquil-2-acetilglicerofosfocolina Esterase/metabolismo , Proteína C-Reativa/metabolismo , Citocinas , Bases de Dados Bibliográficas/estatística & dados numéricos , Fibrinogênio , Humanos , Fatores de Risco , Acidente Vascular Cerebral/epidemiologiaRESUMO
OBJECTIVE: To examine the dynamics of intracranial venous flow patterns in patients with idiopathic intracranial hypertension (IIH). METHODS: Nonrandomized controlled trial analyzing the difference in cerebral perfusion in 13 IIH patients and 12 healthy controls using contrast-enhanced duplex sonography. In patients, an additional 3D gradient echo magnetic resonance venography (MRV) using a new technique was performed to quantify stenosis of the cerebral sinus. The cerebral perfusion parameters, including cerebral transit time (CTT) and time to peak (TTP), were analyzed. RESULTS: IIH patients had a higher BMI (29.3 [95% CI 26.4, 32.2] vs. 23.3 [95% CI 20.7, 25.9], p = 0.003) and an increased prevalence of headache, but all other clinical characteristics were comparable. The CTT did not differ significantly. The TTP was significantly longer in IIH patients compared to controls (8.5 [95% CI 7.6, 9.4] vs. 7.3 s [95% CI 6.3, 8.1], p = 0.04). Twelve of 13 (92%) IIH patients showed stenosis of the cerebral sinus. CONCLUSIONS: Our study is the first to report an altered cerebral venous flow in IIH patients compared to controls using a dynamic ultrasonographic technique. A simplified MRV technique confirms the high prevalence and reliable detection of venous stenosis in IIH patients.
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Encéfalo/irrigação sanguínea , Encéfalo/fisiopatologia , Pseudotumor Cerebral/diagnóstico por imagem , Pseudotumor Cerebral/fisiopatologia , Adulto , Encéfalo/patologia , Circulação Cerebrovascular/fisiologia , Cavidades Cranianas/patologia , Cavidades Cranianas/fisiopatologia , Feminino , Hemodinâmica/fisiologia , Humanos , Angiografia por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Flebografia/métodos , Pseudotumor Cerebral/patologia , Ultrassonografia Doppler DuplaRESUMO
OBJECTIVES: To compare a 256-slice CT with a simulated standard CT for brain CT perfusion (CTP). METHODS: CTP was obtained in 51 patients using a 256-slice CT (128 detector rows, flying z-focus, 8-cm detector width, 80 kV, 120mAs, 20 measurements, 1 CT image/2.5 s). Signal-to-noise ratios (SNR) were compared in grey and white matter. Perfusion maps were evaluated for cerebral blood flow (CBF), cerebral blood volume (CBV) and mean transit time (MTT) in hypoperfused areas and corresponding contralateral regions. Two reconstructed 10-mm slices for simulation of a standard CT (SDCT) were compared with the complete data sets (large-volume CT, LVCT). RESULTS: Adequate image quality was achieved in 50/51 cases. SNR were significantly different in grey and white matter. A perfusion deficit was present in 27 data sets. Differences between the hypoperfusions and the control regions were significant for MTT and CBF, but not for CBV. Three lesions were missed by SDCT but detected by LVCT; 24 lesions were covered incompletely by SDCT, and 6 by LVCT. 21 lesions were detected completely by LVCT, but none by SDCT. CONCLUSIONS: CTP imaging of the brain using an increased detector width can detect additional ischaemic lesions and cover most ischaemic lesions completely.
Assuntos
Tomografia Computadorizada Multidetectores/métodos , Melhoria de Qualidade , Intensificação de Imagem Radiográfica/métodos , Acidente Vascular Cerebral/diagnóstico por imagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Circulação Cerebrovascular/fisiologia , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Perfusão , Padrões de Referência , Estudos Retrospectivos , Sensibilidade e Especificidade , Estatísticas não Paramétricas , Acidente Vascular Cerebral/diagnósticoRESUMO
BACKGROUND: Plaque imaging based on magnetic resonance imaging (MRI) represents a new modality for risk assessment in atherosclerosis. It allows classification of carotid plaques in high-risk and low-risk lesion types (I-VIII). Type 2 diabetes mellitus (DM 2) represents a known risk factor for atherosclerosis, but its specific influence on plaque vulnerability is not fully understood. This study investigates whether MRI-plaque imaging can reveal differences in carotid plaque features of diabetic patients compared to nondiabetics. METHODS: 191 patients with moderate to high-grade carotid artery stenosis were enrolled after written informed consent was obtained. Each patient underwent MRI-plaque imaging using a 1.5-T scanner with phased-array carotid coils. The carotid plaques were classified as lesion types I-VIII according to the MRI-modified AHA criteria. For 36 patients histology data was available. RESULTS: Eleven patients were excluded because of insufficient MR-image quality. DM 2 was diagnosed in 51 patients (28.3%). Concordance between histology and MRI-classification was 91.7% (33/36) and showed a Cohen's kappa value of 0.81 with a 95% CI of 0.98-1.15. MRI-defined high-risk lesion types were overrepresented in diabetic patients (n = 29; 56.8%). Multiple logistic regression analysis revealed association between DM 2 and MRI-defined high-risk lesion types (OR 2.59; 95% CI [1.15-5.81]), independent of the degree of stenosis. CONCLUSION: DM 2 seems to represent a predictor for the development of vulnerable carotid plaques irrespective of the degree of stenosis and other risk factors. MRI-plaque imaging represents a new tool for risk stratification of diabetic patients.
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Estenose das Carótidas/diagnóstico , Estenose das Carótidas/epidemiologia , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/epidemiologia , Imageamento por Ressonância Magnética/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Feminino , Alemanha/epidemiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Medição de Risco/métodos , Fatores de Risco , Sensibilidade e EspecificidadeRESUMO
BACKGROUND AND PURPOSE: Despite numerous studies suggesting a relationship between paradoxical embolism from a patent foramen ovale (PFO) and stroke, the role of PFO as a risk factor for cerebral ischaemia remains controversial. We therefore sought to determine the association between a RLS detected by contrast-enhanced transcranial Doppler ultrasonography (c-TCD) and recurrent stroke in an unselected population sample. METHODS: We analyzed the records of 763 patients with diagnosis of cerebral ischaemia at our institution. All patients had undergone TCD-based detection of RLS. Embolic signals have been measured both under resting conditions and after performing a Valsalva maneuver. For follow-up, all patients were contacted by mail, which included a standardized questionnaire. Endpoints of follow-up were defined as recurrence of cerebral ischaemia, occurrence of myocardial infarction or death from any cause. RESULTS: Follow-up data were available in 639 patients (83.7%). At baseline, a RLS was detected in 140 (28%) men and in 114 (42%) women. Ten shunt-carriers (1.6%) and 32 patients (5.0%) without RLS had suffered a recurrent stroke. After adjustment for age, sex, and atrial fibrillation, the hazard ratio of RLS for stroke recurrence was 0.86 (95% CI 0.41-1.79). The condition of RLS at rest adjusted for age, sex, stroke subtype, and cardiovascular risk factors was not found to increase the risk of stroke substantially (HR 1.16 [95% CI 0.41-3.29]) CONCLUSION: Our data suggest that the risk of recurrent stroke in subjects with PFO is not significantly increased in comparison with subject without it.
Assuntos
Forame Oval Patente/complicações , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia , Adulto , Fatores Etários , Idoso , Estudos de Coortes , Eletrocardiografia , Feminino , Frequência Cardíaca/fisiologia , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/complicações , Infarto do Miocárdio/etiologia , Exame Neurológico , Inibidores da Agregação Plaquetária/uso terapêutico , Modelos de Riscos Proporcionais , Recidiva , Síndrome das Pernas Inquietas/complicações , Síndrome das Pernas Inquietas/etiologia , Fatores de Risco , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/mortalidade , Ultrassonografia Doppler Transcraniana/métodosRESUMO
OBJECTIVES: The search for markers predicting risk of plaque rupture in carotid atherosclerosis is still ongoing. Previous findings showed that pregnancy-associated plasma protein-A (PAPP-A) levels correlate with an adverse plaque morphology. However, the role of PAPP-A in plaque destabilisation is still uncertain. MATERIAL AND METHODS: Patients with carotid artery stenosis involved in the study were asymptomatic (n=29) and symptomatic (n=37). Carotid plaques were characterised by histology (n=33). Immunohistochemistry (n=17) was used to determine expression of PAPP-A and CD68 within the plaques. Serum levels of PAPP-A were measured by the enzyme-linked immunosorbent assay (ELISA). RESULTS: Circulating PAPP-A levels were significantly higher in patients with unstable versus stable plaques (0.10+/-0.06 vs. 0.07+/-0.04 microg ml(-1), p=0.047) and interestingly, in asymptomatic versus symptomatic patients (0.11+/-0.05 vs. 0.069+/-0.09 microg ml(-1), p=0.025). These differences remained statistically significant after adjustment for age, gender and degree of stenosis (p=0.050). PAPP-A expression in plaques correlated significantly with CD68 positive macrophages, cap-thickness and its serological values (r=+0.291, p<0.001, r=-0.639, p<0.001 and r=0.618, p<0.008, respectively). Furthermore, PAPP-A serum values demonstrated a significant positive predictive value of 68.8% for unstable plaques. CONCLUSION: Our present data confirmed the close relationship between expression of PAPP-A and plaque instability and furthermore correlated significantly with cap thickness. However, the question whether PAPP-A is a useful predictive marker of plaque instability remains unresolved.
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Aterosclerose/sangue , Biomarcadores/sangue , Estenose das Carótidas/sangue , Proteína Plasmática A Associada à Gravidez/biossíntese , Idoso , Aterosclerose/complicações , Aterosclerose/patologia , Estenose das Carótidas/etiologia , Estenose das Carótidas/patologia , Ensaio de Imunoadsorção Enzimática , Feminino , Seguimentos , Humanos , Imuno-Histoquímica , Masculino , Prognóstico , Estudos Prospectivos , Índice de Gravidade de DoençaRESUMO
OBJECTIVES: Increased carotid intima-media thickness (C-IMT) is a non-invasive marker of atherosclerosis and predicts vascular events. Moreover, increasing evidence suggests an association between carotid atherosclerosis and cognitive decline. The purpose of this study is to investigate the relationship between C-IMT and the development of cognitive impairment in a large population-based sample. METHODS: This study was based on the data of the participants of the INVADE (Intervention project on cerebrovascular diseases and dementia in the district of Ebersberg, Bavaria) project. Vascular risk factors, Geriatric depression scale (GDS) and "6 Item Cognitive Impairment Test" (6CIT) were evaluated at baseline and after 2 years. The relationship between C-IMT and cognitive impairment was analysed using multivariate logistic regression. RESULTS: Complete baseline data were available in 3386 subjects (mean age 67.7 [95% confidence interval (CI): 67.5, 68.0] years, 41% male). During follow-up, 174 subjects developed a new cognitive impairment. In the subgroup without cognitive impairment at baseline a significant association between cognitive decline after 2 years and elevated C-IMT at baseline could be detected with a significantly higher baseline C-IMT in those with cognitive decline (0.87 mm vs. 0.78 mm; p < 0.0001). After adjustment for various risk factors only age, GDS baseline 6CIT and C-IMT were independently associated with the development of a new cognitive impairment. CONCLUSIONS: Our data indicate that an increased carotid intima-media thickness predicts a cognitive decline in an elderly population without prevalent cognitive impairment.
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Artéria Carótida Primitiva/patologia , Transtornos Cognitivos/patologia , Túnica Íntima/patologia , Túnica Média/patologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Transtornos Cognitivos/diagnóstico , Estudos de Coortes , Feminino , Humanos , Masculino , Análise Multivariada , Valor Preditivo dos Testes , Escalas de Graduação Psiquiátrica , Fatores de RiscoRESUMO
BACKGROUND AND PURPOSE: Despite numerous studies, the role of patent foramen ovale (PFO) as a risk factor for stroke due to paradoxical embolism is still controversial. On the assumption that specific lesion patterns, in particular multiple acute ischaemic lesions on diffusion-weighted magnetic resonance imaging, indicate a cardioembolic origin, we compared the MRI findings in stroke patients with right-to-left shunt (RLS) and those without. METHODS: The records of 486 patients with diagnosis of cerebral ischaemia were reviewed. For detection of RLS, contrast-enhanced transcranial Doppler (c-TCD) was carried out in all patients. An MRI scan of the brain was performed in all patients. Affected vascular territories were divided into anterior cerebral artery, middle cerebral artery, vertebrobasilar artery system including posterior cerebral artery, brain stem and cerebellar stroke, and strokes occurring in more than one territory. RESULTS: We did not find a specific difference in neuroradiological lesion patterns in patients with RLS compared with patients without RLS. In particular, 23 of 165 patients (13.9%) with RLS showed multiple ischaemic lesions on MRI in comparison with 45 of 321 patients (14.0%) without RLS (P = 0.98). These findings also applied for the subgroup of cryptogenic strokes with and without RLS. CONCLUSION: We found no association between an ischaemic lesion pattern that is considered as being typical for stroke due to cardiac embolism and the existence of PFO. Therefore, our findings do not provide any support for the common theory of paradoxical embolism as a major cause of stroke in PFO carriers.
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Isquemia Encefálica/etiologia , Encéfalo/irrigação sanguínea , Encéfalo/fisiopatologia , Embolia Paradoxal/complicações , Forame Oval Patente/complicações , Idoso , Isquemia Encefálica/diagnóstico por imagem , Distribuição de Qui-Quadrado , Embolia Paradoxal/diagnóstico por imagem , Feminino , Forame Oval Patente/diagnóstico por imagem , Humanos , Angiografia por Ressonância Magnética , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Estudos Retrospectivos , Fatores de Risco , UltrassonografiaRESUMO
BACKGROUND AND PURPOSE: Asymptomatic peripheral arterial disease (PAD) is very common in the elderly and can be detected in 15-20% of patients above 55 years. The aim of this study was to determine PAD prevalence and risk factors within the population of the overall INVADE project (INtervention project of cerebroVAscular diseases and Dementia in the District of Ebersberg [Bavaria]), a prospective non-randomized analysis. PATIENTS AND METHODS: A total of 3,909 participants were included in the INVADE project. An ankle-brachial index (ABI) measurement was available in 3 891 subjects. An additional 40 patients were excluded because their ABI was >1,5. The analysis was thus based on 3,851 participants. The mean age was 70.1 years (95% confidence interval: 69,8 - 70,3). There were 2 285 (59.3%) women. The changes of the different classical vascular and risk factors as well as various laboratory parameters, including high sensitivity C-reactive protein (hs-CRP) were recorded and analysed by the paired t-test or the Fisher's exact test. Independent predictors were calculated by multiple logistic regression analysis. RESULTS: The prevalence of PDA was 18.6%. In 75% of the PAD patients the diagnosis had been unknown before study onset. Those with PAD were significant younger (69.6 vs. 72.2 years; p<0.0001), had significant lower hsCRP values (3,8 mg/l vs. 4.9 mg/l; p=0.002) and a lower vascular risk profile. After two years of intervention an improvement of vascular risk factors and reduction in necessary treatment, such as antihypertensives and platelet inhibitors, was documented. Independent risk factors for PAD development, in addition to the baseline ABI, were age, years of smoking (packs per day) and hsCRP. CONCLUSION: The INVADE project confirms the high prevalence of PAD in an elderly population. These data underline the importance of measuring hsCRP for diagnosing and following PAD development.
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Doenças Vasculares Periféricas/epidemiologia , Fatores Etários , Idoso , Anti-Hipertensivos/uso terapêutico , Proteína C-Reativa/análise , Estudos de Coortes , Feminino , Alemanha/epidemiologia , Humanos , Modelos Logísticos , Masculino , Doenças Vasculares Periféricas/diagnóstico , Doenças Vasculares Periféricas/tratamento farmacológico , Inibidores da Agregação Plaquetária/uso terapêutico , Prevalência , Estudos Prospectivos , Fatores de Risco , Fumar/efeitos adversosRESUMO
BACKGROUND AND PURPOSE: Carotid artery stenosis can be classified by magnetic resonance imaging (MRI) as lesion types I-VIII according to a modified histological scheme based on American Heart Association (AHA) guidelines. Lesion types IV-V and VI are regarded as high-risk plaques.We aimed to evaluate the clinical relevance of this classification for identifying unstable plaques. METHODS: Eighty-five patients (29 female) with severe carotid artery stenosis (diagnosed by Doppler and duplex ultrasonography) were imaged using a 1.5 T scanner with bilateral phased-array carotid coils. T1-, T2-, time-offlight (TOF) and proton-density (PD)-weighted studies were obtained. The carotid plaques were classified as lesion types III-VIII according to the MRI-modified AHA criteria. RESULTS: Thirty-five patients presented with a recently symptomatic stenosis; 50 patients were asymptomatic. Lesion types IV-V (51.4 % vs. 22 %) and VI (20 % vs. 4%; P < 0.0001) were found significantly more often in symptomatic patients compared to those without a history of cerebral ischemia. CONCLUSIONS: The distribution of lesion types differs significantly between symptomatic and asymptomatic carotid artery stenosis. High-risk lesion types IV-V and VI were overrepresented in recently symptomatic patients. MRI according to the modified AHA-criteria may be a suitable tool for detection of unstable carotid lesions.
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Artérias Carótidas/patologia , Estenose das Carótidas/diagnóstico , Imageamento por Ressonância Magnética/métodos , Idoso , Idoso de 80 Anos ou mais , Artérias Carótidas/diagnóstico por imagem , Estudos de Avaliação como Assunto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Ultrassonografia Doppler DuplaRESUMO
Stroke is the leading cause of long-term major disability in developed countries, although several improvements could be achieved in acute stroke therapy (e. g. thrombolysis, stroke-unit treatment, optimized early rehabilitation strategies). Therefore, primary prevention is essential to reduce the burden of stroke. 10 -20 % of all cerebral ischemias are caused due to stenosis or occlusion of the extracranial carotid arteries. This review summarizes the indications, diagnostics as well as the actual data for a medical, endovascular or operative treatment of asymptomatic carotid stenosis.
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Estenose das Carótidas/diagnóstico , Estenose das Carótidas/complicações , Estenose das Carótidas/terapia , Diagnóstico Diferencial , Humanos , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controleRESUMO
BACKGROUND: Diffusion-weighted imaging (DWI) abnormalities can frequently be detected after carotid endarterectomy (CEA) and carotid angioplasty with stent placement (CAS) of the carotid arteries. We looked for possible predictors for the development of DWI lesions during the intervention. METHODS: We investigated 41 patients who underwent CAS without protection devices and 93 patients who underwent CEA. DWI studies were performed 1 day before and after the intervention. RESULTS: Ischemic complications consisted of two strokes (2.2%) in the CEA group and one stroke (2.4%) in the CAS group. DWI lesions were detected in 28.0% of all patients after intervention. Using a multivariate regression analysis, diabetes mellitus (DM), hyperlipidemia, symptomatic stenosis, age and CAS were found to be significant predictors for the occurrence of DWI lesions. CONCLUSIONS: DWI is an objective and highly sensitive method for monitoring interventions of the carotid arteries. Our results point to an increased risk of patients with diabetes and hyperlipidemia to develop DWI lesions during invasive therapy of the ICA.
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Estenose das Carótidas/patologia , Estenose das Carótidas/cirurgia , Imagem de Difusão por Ressonância Magnética , Fatores Etários , Idoso , Angioplastia com Balão , Estenose das Carótidas/complicações , Diabetes Mellitus/fisiopatologia , Endarterectomia das Carótidas , Feminino , Humanos , Hiperlipidemias/complicações , Masculino , Análise Multivariada , Estudos Prospectivos , Fatores de Risco , StentsRESUMO
BACKGROUND AND PURPOSE: Significant improvements of cerebral vasomotor reactivity during statin treatment were found in patients with cerebral small-vessel disease. The authors analyzed the cerebrovascular CO(2) reactivity before and after statin administration in healthy adults using a case-control study design. METHODS: The mean cerebral blood flow velocity (CBFV) of both middle cerebral arteries and the vasomotor reserve capacity (VMRC) were measured by repeated and simultaneous bilateral transcranial Doppler sonography in 25 healthy adults (7 men, mean age 28.8 years [95% confidence interval (CI): 25.7; 31.9]) before, during (days 1, 3, 7, and 14), and after administration of 40 mg pravastatin for 14 days as compared to 10 healthy control persons (4 men, mean age 30.6 years [95% CI: 22.9; 38.3]). The VMRC was calculated off-line as the percentage change of CBFV per 1% increase in end-tidal CO2 by a blinded investigator. RESULTS: In the statin group, 5 persons were excluded from further analysis. In the remaining 20 volunteers, the authors observed a highly significant effect of statin administration on VMRC (P = .002). The VMRC was significantly increased after statin administration on day 7 as compared to the initial value (3.03 [95% CI: 2.67; 3.38] vs 2.64 [95% CI: 2.41; 2.86]; P = .04). The effect was most pronounced in patients with lower initial VMRC values. In the control group, the VMRC did not differ significantly from baseline at different time intervals. CONCLUSIONS: The findings indicate an improvement of cerebral vasoreactivity even after short-term statin administration in healthy adults. However, this effect was related to baseline vasoreactivity.
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Inibidores de Hidroximetilglutaril-CoA Redutases/farmacologia , Artéria Cerebral Média/fisiologia , Pravastatina/farmacologia , Sistema Vasomotor/fisiologia , Adulto , Velocidade do Fluxo Sanguíneo/efeitos dos fármacos , Estudos de Casos e Controles , Circulação Cerebrovascular , Feminino , Humanos , Masculino , Artéria Cerebral Média/efeitos dos fármacos , Ultrassonografia Doppler Transcraniana , Sistema Vasomotor/efeitos dos fármacosRESUMO
OBJECTIVES: Neurological deficit defines the outcome of Carotid Endarterectomy (CEA) that is mainly caused by cerebral ischemia. Diffusion-weighted imaging (DWI) is a sensitive method for demonstrating even small ischemic lesions. The aim of this study was to evaluate the frequency, clinical significance and course of ischemic lesions after CEA using serial DWI. METHODS: DWI was performed within 1 day before and after CEA in 88 patients. Postoperative lesions were analyzed by their quantity, volume and distribution. To differentiate temporary ischemia from definite cerebral infarction (blood brain barrier disruption) all patients with a positive postoperative DWI were reexamined with contrast-enhanced T1-MRI 7-10 days after the procedure. All patients were examined by a neurologist within 2 days before and after CEA. RESULTS: Two patients showed a postoperative neurological deficit. Postoperative DWI revealed ipsilateral ischemic lesions in 15 patients. In seven of these patients a brain infarction was diagnosed on the T1-MRI during follow-up. A significant correlation between the number of DWI lesions (p=0.031) as well as the volume of DWI lesions (p=0.023) and definite infarction was found. Symptomatic patients preoperatively showed significantly more DWI lesions (p=0.036) and cerebral infarcts (p=0.003). CONCLUSION: DWI is a sensitive method of demonstrating ischemic events after CEA. The number and volume of DWI lesions after CEA are highly predictive of brain infarction.