Ultrasound Examination of the Pupil - A New Tool for the Neuro-Ophthalmological Assessment.

BACKGROUND: Pupil examination represents a diagnostic and prognostic test in the management of several neurological diseases. Infrared video pupillometry (IVP) is the gold standard, since it is not routinely available, a noninvasive bedside ultrasound assessment has been proposed as an alternative. The aim of this study was to assess the feasibility and reproducibility of ultrasound pupillometry (UP) in comparison with IVP. MATERIALS AND METHODS: 81 subjects (43 men and 38 women, mean age: 52 ±â€Š20 years and 49 ±â€Š19 years, respectively) with no history of neurophthalmologic disease were enrolled. UP was performed with a 12-MHz linear probe according to current guidelines for orbital insonation. Light and painful stimuli were applied to test pupillary light reflex (PLR) and ciliospinal reflex (CR). In 30 of these subjects IVP examination was performed additionally to obtain intra-observer and inter-observer agreement. RESULTS: Increasing age was associated with a decreased pupillary diameter (PD) at rest, after PLR and CR (R -0.728, p < 0.01, R -0.643, p < 0.01, R 0.674, p < 0.001 respectively), while no association was noticed with time to constriction/dilation. UP measurements were reproducible (rate of inter- and intra-observer agreement: R 0.979, p < 0.01, R 0.946, p < 0.01 respectively) and concordant with IVP (PLR R 0.831, p < 0.01; CR R 0.879, p < 0.01). CONCLUSION: According to our study, ultrasound pupillometry is a feasible and reliable technique for bedside pupillary function assessment, and is a good alternative to infrared video pupillometry. Moreover, it represents the only way for functional pupillary assessment in patients with periorbital hematoma.

GEN-O-MA project: an Italian network studying clinical course and pathogenic pathways of moyamoya disease-study protocol and preliminary results.

BACKGROUND: GENetics of mOyaMoyA (GEN-O-MA) project is a multicenter observational study implemented in Italy aimed at creating a network of centers involved in moyamoya angiopathy (MA) care and research and at collecting a large series and bio-repository of MA patients, finally aimed at describing the disease phenotype and clinical course as well as at identifying biological or cellular markers for disease progression. The present paper resumes the most important study methodological issues and preliminary results. METHODS: Nineteen centers are participating to the study. Patients with both bilateral and unilateral radiologically defined MA are included in the study. For each patient, detailed demographic and clinical as well as neuroimaging data are being collected. When available, biological samples (blood, DNA, CSF, middle cerebral artery samples) are being also collected for biological and cellular studies. RESULTS: Ninety-eight patients (age of onset mean ± SD 35.5 ± 19.6 years; 68.4% females) have been collected so far. 65.3% of patients presented ischemic (50%) and haemorrhagic (15.3%) stroke. A higher female predominance concomitantly with a similar age of onset and clinical features to what was reported in previous studies on Western patients has been confirmed. CONCLUSION: An accurate and detailed clinical and neuroimaging classification represents the best strategy to provide the characterization of the disease phenotype and clinical course. The collection of a large number of biological samples will permit the identification of biological markers and genetic factors associated with the disease susceptibility in Italy.

The perioperative outcomes of eversion carotid endarterectomy in diabetic patients aged 80 years or older.

BACKGROUND: Uncertainty exists about the influence of advanced age and diabetes mellitus on the clinical effect of carotid endarterectomy (CEA). This study analyzed the perioperative (30-day) outcomes of CEA in diabetic patients aged ≥80 years. METHODS: Data of 1872 consecutive patients who underwent 2125 primary eversion CEAs from 1990 to 2014 at our institution were prospectively stored in a vascular surgery registry. Risk factors, medication, and indication for surgery were recorded. The 354 patients (387 CEAs) aged ≥80 years formed the study base; of whom, 207 (219 CEAs) were diabetic and 147 (168 CEAs) were not. A neurologist assessed all patients preoperatively, on waking from the anesthesia, and before discharge from the hospital. All procedures were eversion CEA performed by the same surgeon under general anesthesia with routine electroencephalographic monitoring for selective shunting. RESULTS: Diabetic patients were more likely to have arterial hypertension (P = .033), cardiac disease (P = .038), peripheral aneurysmal/atherosclerotic disease (P = .046), and contralateral carotid occlusion (P = .042) than their nondiabetic counterparts. Overall, there were no deaths, two (0.51%) perioperative strokes (both in diabetic patients), and 13 nonfatal cardiac complications (3.3%), of which 10 occurred in diabetic patients, but the difference failed to reach statistical significance. CONCLUSIONS: Findings from this study show that CEA is safe and effective for stroke prevention in diabetic patients aged ≥80 years, with a negligible incidence of perioperative adverse events and no deaths.

Jugular veins in transient global amnesia: innocent bystanders.

BACKGROUND AND PURPOSE: Transient global amnesia (TGA) has been associated with an increased prevalence of internal jugular valve insufficiency and many patients report Valsalva-associated maneuvers before TGA onset. These findings have led to the assumption of hemodynamic alterations in intracranial veins inducing focal hippocampal ischemia. We investigated this hypothesis in patients with TGA and control subjects. METHODS: Seventy-five patients with TGA and 75 age- and sex-matched healthy subjects were enrolled into a cross-sectional study. Extracranial and transcranial high-resolution venous echo-color-Doppler sonography was performed blindly in all patients and control subjects. Blood flow direction and velocities were recorded at the internal jugular veins, basal veins of Rosenthal, and vein of Galen, both at rest and during Valsalva-associated maneuvers. RESULTS: Mean age of patients with TGA was 60.3±8.0 years (median, 60 years; range, 44-78 years); 44 (59%) were female (female/male ratio: 1.42). Internal jugular valve insufficiency (left, right, or bilateral) was found to be more frequent in patients with TGA than in control subjects: 53 (70.7%) versus 22 (29.3%; P<0.05). Blood flow velocities in the deep cerebral veins of patients with TGA did not differ from control subjects both at rest and during Valsalva-associated maneuvers. Intracranial venous reflux was neither observed in patients with TGA nor in control subjects despite unilateral or bilateral internal jugular valve insufficiency during prolonged and maximal Valsalva-associated maneuvers. CONCLUSIONS: This study, although confirming the association between TGA and internal jugular valve insufficiency, challenges the hypothesis that cerebral venous congestion plays a significant role in the pathogenesis of TGA.

Genetic and environmental factors on heart rate, mean arterial pressure and carotid intima-media thickness: A longitudinal twin study.

BACKGROUND: Heart rate (HR), mean arterial pressure (MAP) and carotid intima-media thickness (cIMT) are moderately heritable cardiovascular traits, but the environmental effects on the longitudinal change of their heritability have never been investigated. METHODS: 368 Italian and Hungarian twins (107 monozygotic, 77 dizygotic) underwent oscillometric measurement and B-mode sonography of bilateral carotid arteries in 2009/2010 and 2014. Within- -individual/cross-study wave, cross-twin/within-study wave and cross-twin/cross-study wave correlations were estimated, and bivariate Cholesky models were fitted to decompose the total variance at each wave and covariance between study waves into additive genetic, shared and unique environmental components. RESULTS: For each trait, a moderate longitudinal stability was observed, with within-individual/crosswave correlations of 0.42 (95% CI: 0.33-0.51) for HR, 0.34 (95% CI: 0.24-0.43) for MAP, and 0.23 (95% CI: 0.12-0.33) for cIMT. Cross-twin/cross-wave correlations in monozygotic pairs were all significant and substantially higher than the corresponding dizygotic correlations. Genetic continuity was the main source of longitudinal stability, with across-time genetic correlations of 0.52 (95% CI: 0.29-0.71) for HR, 0.56 (95% CI: 0.31-0.81) for MAP, and 0.36 (95% CI: 0.07-0.64) for cIMT. Overlapping genetic factors explained respectively 57%, 77%, and 68% of the longitudinal covariance of the HR, MAP and cIMT traits. CONCLUSIONS: Genetic factors have a substantial role in the longitudinal change of HR, MAP and cIMT; however, the influence of unique environmental factors remains relevant. Further studies should better elucidate whether epigenetic mechanisms have a role in influencing the stability of the investigated traits over time.

Early hemodynamic predictors of good outcome and reperfusion injury after endovascular treatment.

OBJECTIVE: To find early hemodynamic predictors of outcome and reperfusion injury in patients with acute ischemic stroke due to anterior circulation large artery occlusion (LAO) after endovascular treatment (EVT). METHODS: Serial transcranial color-coded sonography examinations assessed the vessel status and cerebral hemodynamics of 185 (109 [58.9%] men, mean age 69.5 ± 12.3 years) consecutive patients with acute anterior circulation LAO soon after, at 48 hours after, and 1 week after EVT. RESULTS: Successful recanalization (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.11-0.61) and normal peak systolic velocity (PSV) ratio (PSV of recanalized middle cerebral artery/PSV of contralateral middle cerebral artery) at 48 hours (OR 0.22, 95% CI 0.15-0.64) and after 1 week (OR 0.11, 95% CI 0.07-0.31) from EVT were independent predictors of good outcome at 3 months. Thrombectomy failure (OR 10.22, 95% CI 1.47-45.53) and pathologic PSV ratio at 1 week from EVT (OR 15.23, 95% CI 4.54-46.72) were associated with a worse 90-day outcome. Patients who subsequently developed postinterventional intracranial hemorrhage (ICH) showed a higher mean PSV ratio (3.5 ± 0.2 vs 2.4 ± 0.1, p < 0.0001) soon after successful recanalization. In multivariate analysis, early PSV ratio was independently associated with postprocedural ICH (OR 8.474, 95% CI 3.066-45.122, p < 0.01]. At 1 week from EVT, 15 of 21 (71.4%) patients with ICH who resumed normal PSV values had a better 90-day outcome (modified Rankin Scale score 0-2: 40% vs 0%). CONCLUSION: Post-EVT ultrasound monitoring of stroke patients might be an effective bedside method for assessing treatment efficacy, shedding light on outcome variability and identifying patients at increased risk of ICH.

Ultrasound Identification of Patients at Increased Risk of Intracranial Hemorrhage After Successful Endovascular Recanalization for Acute Ischemic Stroke.

BACKGROUND: Intracranial hemorrhage (ICH) is the most feared complication of endovascular treatment (EVT) for acute ischemic stroke because of anterior circulation large vessel occlusion (LVO). The purpose of this study was to identify cerebral hemodynamic predictors of ICH and poor outcome in patients with successful recanalization. METHODS: Serial transcranial color-coded sonography (TCCS) examinations assessed vessel status and cerebral hemodynamics of 226 (mean age, 69.8 ± 12.5 years; 130 men [57.5%]) consecutive patients with acute anterior circulation LVO at 48 hours and 1 week after EVT. Middle cerebral artery peak systolic velocity (PSVMCA) and PSVMCA ratio (recanalized PSVMCA/contralateral PSVMCA) were recorded. RESULTS: Out of 180 successfully recanalized patients (79.6%), 28 patients (15.5%) had ICH. They more often had arterial hypertension (25/28 [89.3%] vs. 106/152 [69.7%], P = 0.04), a more severe stroke syndrome (18 [range, 10-23] vs. 16 [range, 5-26], P = 0.01), a worse clinical outcome (90-day modified Rankin Scale [mRS] score 3-5: 16/28 [57.1%] vs. 42/152 [27.6%], P = 0.004), and soon after EVT showed a significantly higher mean PSVMCA ratio (3.4 ± 0.1 vs. 2.4 ± 0.1, P < 0.0001) than patients without ICH, respectively. In multivariate analysis, early PSVMCA ratio was independently associated with postinterventional ICH (odds ratio, 13.379; 95% confidence interval, 2.466-50.372; P < 0.01). The patients with ICH (19/28 [67.9%]) who resumed normal PSVMCA values at 1 week after EVT had a better outcome (90-day mRS score 0-2: 8/19 [42.1%] vs. 0/9 [0%], respectively). CONCLUSIONS: Early TCCS detection of a high PSVMCA ratio in successfully recanalized stroke patients indicates an increased risk of ICH, whereas cerebral hemodynamics normalization at 1 week in patients with postinterventional ICH predicts a relatively better 3-month outcome.

Surface-Limited Electrodeposition of Continuous Platinum Networks on Highly Ordered Pyrolytic Graphite.

Continuous thin platinum nanoplatelet networks and thin films were obtained on the flat surface of highly ordered pyrolytic graphite (HOPG) by high overpotential electrodeposition. By increasing the deposition time, the morphology of the Pt deposits can be progressively tuned from isolated nanoplatelets, interconnected nanostructures, and thin large flat islands. The deposition is surface-limited and the thickness of the deposits, equivalent to 5 to 12 Pt monolayers, is not time dependent. The presence of Pt (111) facets is confirmed by High Resolution Transmission Electron Microscopy (HRTEM) and evidence for the early formation of a platinum monolayer is provided by Scanning Transmission Electron Microscopy and Energy Dispersive X-rays Spectroscopy (STEM-EDX) and X-ray Photoelectron Spectroscopy (XPS) analysis. The electroactivity towards the oxygen reduction reaction of the 2D deposits is also assessed, demonstrating their great potential in energy conversion devices where ultra-low loading of Pt via extended surfaces is a reliable strategy.

Electrodeposition of Two-Dimensional Pt Nanostructures on Highly Oriented Pyrolytic Graphite (HOPG): The Effect of Evolved Hydrogen and Chloride Ions.

We discuss the electrodeposition of two-dimensional (2D) Pt-nanostructures on Highly Oriented Pyrolytic Graphite (HOPG) achieved under constant applied potential versus a Pt counter electrode (Eappl = ca. -2.2 V vs. NHE, normal hydrogen electrode). The deposition conditions are discussed in terms of the electrochemical behavior of the electrodeposition precursor (H2PtCl6). We performed cyclic voltammetry (CV) of the electrochemical Pt deposit on HOPG and on Pt substrates to study the relevant phenomena that affect the morphology of Pt deposition. Under conditions where the Pt deposition occurs and H2 evolution is occurring at the diffusion-limited rate (-0.3 V vs. NHE), Pt forms larger structures on the surface of HOPG, and the electrodeposition of Pt is not limited by diffusion. This indicates the need for large overpotentials to direct the 2D growth of Pt. Investigation of the possible effect of Cl- showed that Cl- deposits on the surface of Pt at low overpotentials, but strips from the surface at potentials more positive than the electrodeposition potential. The CV of Pt on HOPG is a strong function of the nature of the surface. We propose that during immersion of HOPG in the electrodeposition solution (3 mM H2PtCl6, 0.5 M NaCl, pH 2.3) Pt islands are formed spontaneously, and these islands drive the growth of the 2D nanostructures. The reducing agents for the spontaneous deposition of Pt from solution are proposed as step edges that get oxidized in the solution. We discuss the possible oxidation reactions for the edge sites.

Prognostic Role of Microembolic Signals After Endovascular Treatment in Anterior Circulation Ischemic Stroke Patients.

BACKGROUND: Endovascular treatment (EVT) is an effective therapy for acute ischemic stroke due to large artery occlusion of the anterior circulation. Yet some patients do not experience clinical improvement despite successful recanalization and reperfusion. The reasons are unknown, but one possible explanation is microvessel obstruction downstream. The aim of this study was to assess the presence of microembolic signals (MES) with transcranial Doppler and define their role as predictors of clinical outcome in stroke patients after EVT. MATERIALS AND METHODS: We enrolled 40 consecutive patients (23 men, mean age 65.8 ± 7.6 years) with an acute ischemic stroke caused by large artery occlusion of the anterior circulation who underwent EVT. Presence and rate of MES were assessed by 60-minute transcranial Doppler monitoring at the end of the procedure and after 15 days from stroke onset. RESULTS: MES were detected in 65% (26/40) of patients after EVT. Ipsilateral carotid occlusion (P = 0.05), ≥50% ipsilateral carotid stenosis (P = 0.05), incomplete recanalization (P = 0.03), and inadequate collaterals (P = 0.04) were associated with a significantly higher MES count, which was correlated with a worse functional prognosis (P = 0.03), higher mortality (P = 0.02), higher distal embolization burden even outside the original ischemic territory (P = 0.02), and higher risk of cardiovascular events (P = 0.04). CONCLUSIONS: MES monitoring in stroke patients after EVT provides useful prognostic information, sheds light on the lack of clinical improvement despite successful recanalization, and might guide medical treatment in higher risk patients.

Vertebral artery hypoplasia: an innocent lamb or a disguise?

BACKGROUND: The role of vertebral artery hypoplasia (VAH) in stroke pathophysiology is still debated. In this study, we correlated extra- and intra-cranial vertebral artery ultrasound findings with brain CT/MRI and clinical outcome. MATERIALS AND METHODS: We recruited all consecutive first-ever stroke patients with a documented acute ischemic brain lesion and a complete extra-intracranial ultrasound evaluation. Those with previous stroke, or with anterior and posterior strokes were excluded. The prevalence of VAH diagnosed by ultrasound was recorded both in anterior circulation and posterior circulation infarctions. In the latter group, we compared the risk profile, topographic and neuroradiological lesion features, etiology and clinical outcome based on the presence of VAH. RESULTS: The study included 750 patients [436 males (58%); mean age 65 years; age range 18-90] with first-ever acute ischemic stroke: 193 (25.7%) with a posterior circulation infarction, 557 (74.3%) with an anterior circulation infarction. VAH was more often detected in the former group (33.7 vs. 14.1%; p < 0.0001). Patients with posterior circulation stroke and VAH had a significantly higher frequency of basilar artery stenosis [OR 2.07 (1.00-4.26); p < 0.05], stenosis of the contralateral vertebral artery [64 vs. 36%; OR 3.22 (1.24-8.37); p < 0.05], and fetal-type variant of the posterior cerebral artery [25 vs. 13%; OR 2.17 (1.00-4.68); p < 0.05]. CONCLUSIONS: According to our study, VAH identifies patients at higher risk of posterior circulation stroke, and higher frequency of contralateral vertebral artery stenosis and basilar artery stenosis.

Investigation of circle of Willis variants and hemodynamic parameters in twins using transcranial color-coded Doppler sonography.

Morphological and hemodynamic variations of the circle of Willis (CW) may have an important impact on cerebrovascular events. However, the environmental and genetic influence remains unclear. For this reason we studied the variations and hemodynamic parameters of the CW in twins using transcranial color-coded sonography (TCCS). Sixty-four twins, 19 monozygotic (MZ) and 13 dizygotic (DZ) pairs from the Italian Twin Registry (average age 45.0 ± 13.7 years) underwent TCCS and risk factor assessment. We examined CW morphology and recorded peak systolic velocity (PSV), end-diastolic velocity (EDV) and pulsatility index (PI). Raw heritability was determined for hemodynamic parameters, whereas concordance and discordance rates were calculated for CW morphological variants. A normal CW anatomy was observed in the majority of MZ and DZ twins (76.5% and 92.3%, respectively). The most frequent variant was a missing anterior cerebral artery (ACA). There was no significant difference in the prevalence of most CW variants depending on the zigosity. Concordance rates were low regarding the presence of variant CW anatomy both in MZ and DZ groups (0.14 and 0.00, respectively). Women had a significantly higher PI in vertebral arteries (VA) and in the right ACA (p = 0.01, p = 0.02 and p < 0.01, respectively). An inverse correlation was observed between hemodynamic parameters and age. Morphological variants of the CW do not seem to be heritable; they are most likely determined by environmental factors. In contrast, hemodynamic parameters of the CW are moderately heritable and this might have implications in the management and prevention of cerebrovascular diseases.

Heritability of the dimensions, compliance and distensibility of the human internal jugular vein wall.

AIMS: The elasticity of the internal jugular vein (IJV) is a major determinant of cerebral venous drainage and right atrium venous return. However, the level of genetic determination of IJV dimensions, compliance and distensibility has not been studied yet. METHODS: 170 adult Caucasian twins (43 monozygotic [MZ] and 42 dizygotic [DZ] pairs) were involved from the Italian twin registry. Anteroposterior and mediolateral diameters of the IJV were measured bilaterally by ultrasonography. Measurements were made both in the sitting and supine positions, with or without Valsalva maneuver. Univariate quantitative genetic modeling was performed. RESULTS: Genetic factors are responsible for 30-70% of the measured properties of IJV at higher venous pressure even after adjustment for age and gender. The highest level of inheritance was found in the supine position regarding compliance (62%) and venous diameter during Valsalva (69%). Environmental and measurement-related factors instead are more important in the sitting position, when the venous pressure is low and the venous lumen is almost collapsed. The range of capacity changes between the lowest and highest intraluminal venous pressure (full distension range) are mainly determined by genetic factors (58%). CONCLUSIONS: Our study has shown substantial heritability of IJV biomechanics at higher venous pressures even after adjustment for age and gender. These findings yield an important insight to what degree the geometric and elastic properties of the vascular wall are formed by genetic and by environmental factors in humans.

Correction: Heritability of the dimensions, compliance and distensibility of the human internal jugular vein wall.

[This corrects the article DOI: 10.1371/journal.pone.0192948.].

Genetic and environmental determinants of longitudinal stability of arterial stiffness and wave reflection: a twin study.

BACKGROUND: We aimed at evaluating the impact of genetic and environmental factors on longitudinal changes in aortic pulse wave velocity (aPWV) and aortic augmentation index (aAIx). METHOD: Three hundred and sixty-eight Italian and Hungarian adult twins (214 monozygotic, 154 dizygotic) underwent repeated evaluations of aPWV and aAIx (TensioMed Arteriograph). Within-individual/cross-wave, cross-twin/within-wave and cross-twin/cross-wave correlations were calculated; bivariate Cholesky models were fitted to calculate additive genetic (A), shared environmental (C) and unique environmental (E) components. RESULTS: For both aPWV and aAIx, cross-twin correlations in monozygotic pairs (r between 0.35 and 0.56) were all significant and always higher than in dizygotic pairs, both at wave 1 and at wave 2. Heritability and unshared environmental proportion of variance at each wave were substantially time-invariant for aPWV (heritability 0.51, 95% CI 0.36-0.63 at wave 1; 0.49, 95% CI 0.34-0.62 at wave 2), whereas for aAIx, we observed a diminished genetic effect (heritability 0.57, 95% CI 0.45-0.67 at wave 1; 0.37, 95% CI 0.21-0.51 at wave 2). Overlapping genetic factors explained a high proportion (0.88, 95% CI 0.61-1.00) of longitudinal covariance for aPWV, and had a relatively lower impact on aAIx (0.55, 95% CI 0.35-0.70). Genetic correlations of aPWV (r = 0.64, 95% CI 0.42-0.85) and aAIx (r = 0.70, 95% CI 0.52-0.87) between waves were lower than 1, suggesting a potential contribution of novel genetic variance on arterial stiffening. CONCLUSION: Changes in aPWV and aAIx over time are largely genetically determined. Our results might stimulate further studies on genetic and epigenetic factors influencing the process of vascular ageing.

Genetic influence on femoral plaque and its relationship with carotid plaque: an international twin study.

To disentangle genetic and environmental influences on the development of femoral plaques using a population of adult twins. To evaluate the potential role of shared genetic and environmental factors in the co-occurrence of femoral and carotid plaques. The sample included 566 twins belonging to 164 monozygotic (MZ) and 119 dizygotic (DZ) twin pairs, who underwent peripheral arterial assessment by B-mode ultrasound in different centers. The variance in femoral plaques onset was due to genetic factors and the remaining 50% was explained by common (15%) and unique (35%) environmental factors. Findings on sidedness and number of femoral plaques indicated that also these traits were mainly under genetic control. No effect of common environment was found on plaques composition, and variability of this trait was explained by genetics (64%) and unique environment (36%). Covariation between the liabilities to carotid and femoral plaques was mainly attributed to shared genes (77%), with the remaining 23% explained by individual-specific environmental factors shared by the two districts. Inter-individual differences in plaque onset as well as in their number, sidedness and composition are mainly genetic in origin. The results on the cooccurrence of carotid and femoral plaque underline the genetic role in atherogenesis.

Effects of preoperative statin use on perioperative outcomes of carotid endarterectomy.

OBJECTIVES: Several studies have shown the beneficial role of statins in reducing the risk of major perioperative complications and death associated with noncardiac vascular surgery, but few have focused on their effects in the event of carotid endarterectomy (CEA). This study analyzes the effects of preoperative statin use on perioperative outcomes in patients undergoing CEA. MATERIALS AND METHODS: Data from all consecutive patients who underwent primary CEA for symptomatic and asymptomatic carotid disease between 2002 and 2014 at a single institution were prospectively stored in a vascular surgery registry, recording risk factors, medication, and indication for surgery. Endpoints of the study were perioperative (30-day) stroke and death. RESULTS: Overall, 784 patients were on statins (825 CEAs, Group I), while 494 were not (545 CEAs, Group II). There were two perioperative strokes in Group I (0.24%) and four in Group II (0.73%; p = .22), and no deaths. The only nonfatal cardiac complication occurred in Group II (0.18%, p = .39). A neurologist assessed patients at 1, 6, and 12 months after CEA, and every 2 years thereafter. Follow-up (range: 0.1-13 years; mean, 6.3 ± 3.7 years) was obtained for 1,239 patients (1,326 CEAs). Because 165 patients (166 CEAs) crossed over from Group II to Group I during the follow-up time, long-term data were stratified by postoperative statin treatment rather than by preoperative statin use. The 5- and 10-year restenosis/occlusion and survival rates did not differ significantly between the two groups. CONCLUSIONS: Taking statins prior to CEA did not seem to affect the risk of major perioperative ischemic events and death, most likely due to the extremely low overall incidence of perioperative complications.

Safety and Tolerability of SonoVue® in Patients with Large Artery Anterior Circulation Acute Stroke.

BACKGROUND AND PURPOSE: Ultrasound contrast agents (UCAs) are routinely used to improve the visualization of intracranial arteries. Since a higher rate of intracranial hemorrhage (ICH) has been observed in patients undergoing sonothrombolysis in combination with UCAs, we conducted this study with the aim of assessing safety and tolerability of SonoVue® in patients with acute ischemic stroke due to anterior circulation large artery occlusion (LAO) and eligible to intravenous thrombolysis and/or mechanical thrombectomy. METHODS: Among 474 patients consecutively admitted to our Stroke Unit with anterior circulation ischemic stroke, SonoVue® was administered during transcranial ultrasound evaluation to 48 patients with suspected LAO for diagnostic confirmation (group I) and to 44 patients with inadequate temporal bone window. Forty-eight stroke patients with LAO diagnosed only by computed tomography (CT) angiography /magnetic resonance (MR) angiography and matched for age, gender, and National Institutes of Health Stroke Scale score with group I represented the control group (group II). Thrombolysis, thrombectomy, or combined treatment were offered to all eligible patients. Brain MR imaging/CT was performed in both groups in case of neurological deterioration or after 1 week to check for ICH. RESULTS: SonoVue® did not cause any serious adverse event; only mild and transient side effects were reported in six cases (6.5%). Among patients in groups I and II, there were 31 (32.3%) secondary cerebral bleedings with no statistically significant difference between the groups, but only 2 (2.1%) were symptomatic. CONCLUSIONS: According to our study, SonoVue® can be safely administered to acute ischemic stroke patients with suspected anterior circulation LAO and/or inadequate temporal bone window.

"Phacing" a New Cause of Carotid Artery Dissection.

INTRODUCTION: Cervical arterial dissection (CAD) is a frequent and preventable cause of ischemic stroke in young patients. Several arguments suggest that genetic and developmental disorders could play an important role as part of a multifactorial predisposition of sporadic CAD.We present 2 cases of young patients with CAD in association with cutaneous lesions and nonatherosclerotic multivessel arteriopathy. CASE REPORTS: Our first patient was a 17-year-old white girl with sudden onset of weakness in her right upper limb. A magnetic resonance angiogram showed a severe stenosis along the extracranial and intracranial segments of the left internal carotid artery and the left middle cerebral artery. A complete ultrasound study confirmed the stenoses with characteristics suggestive of dissection.Our second patient was a 7-year old white girl with a past history of left middle cerebral artery ischemic stroke. During the follow-up, an ultrasonographical examination discovered an asymptomatic dissection of the right internal carotid artery.Both patients reported a history of large unilateral hemangiomas; in the first case a coloboma of the left optic disc and an aortic aneurysm were also present. These findings were suggestive of PHACE-a neurocutaneous developmental syndrome associated with constitutional arteriopathy of the major cerebral vessels. CONCLUSIONS: Noteworthy, among vascular abnormalities of PHACE, CADs have never been reported before. Our 2 cases suggest that CAD is an underecognized cerebrovascular manifestation of PHACE and it should be searched for in these patients. Ultrasound, being noninvasive and portable, is a useful tool for the assessment and follow-up of these patients.

Stentriever Thrombectomy Failure: A Challenge in Stroke Management.

BACKGROUND AND OBJECTIVE: Stentriever thrombectomy failure in patients with acute ischemic stroke caused by anterior circulation large artery occlusion is not a rare event. The purpose of this study was to investigate whether other procedures (tirofiban, permanent stenting) are able to recanalize the occluded vessel and determine a better outcome without increasing mortality and intracranial hemorrhage rates. METHODS: Among 513 patients consecutively admitted with anterior circulation stroke, 109 underwent stentriever thrombectomy. Modified Thrombolysis in Cerebral Ischemia (mTICI) 2b-3 recanalization was achieved in 60 patients (55.0%, group 1). Only 3 of 19 patients (group 2) obtained additional recanalization with intra-arterial infusion of tirofiban. The remaining 46 either underwent permanent stenting (n = 23, group 3) or were left nonrecanalized (n = 23, group 4). The rate of mTICI 2b-3 and clinical outcomes were analyzed in the different groups. RESULTS: A successful recanalization (mTICI 2b-3) was achieved in 17 patients of group 3 (73.9%). A significantly better outcome was observed in group 3 (modified Rankin Scale [mRS] score, 0-2) than in group 4 at 3 months (56.5% vs. 17.4%). Symptomatic intracranial hemorrhage rates were not different between group 3 and group 4 (4.3% vs. 4.3%), whereas there was a significantly higher mortality in group 4 than in group 3 (39.1% vs. 4.3%). On multivariate analysis, permanent stenting was the only factor independently associated with favorable outcome and mortality. CONCLUSIONS: Permanent stenting might be a feasible solution in patients with acute large artery occlusion after stentriever thrombectomy failure.