Hyperechoic plaque: an ultrasound marker for osteoporosis in acute stroke patients with carotid disease.

BACKGROUND: Osteoporosis is a significant complication of stroke, and hip fracture after a stroke is a frequent problem. Moreover, growing evidence links vascular and bone diseases, in the form of osteoporosis associated with both atherosclerosis and vascular calcification. The aim of our study is to detect bone change in the acute phase of ischemic stroke in patients with carotid disease and to verify the correlation with carotid echogenic plaques. PATIENTS AND METHOD: Out of 245 subjects consecutively admitted to our Stroke Unit for their first ischemic stroke, we selected 49 patients with a first-ever stroke due to carotid atherosclerosis without a previous diagnosis of bone disease. We assessed risk factors for cerebrovascular disease as well as for osteoporosis, the degree of neurological deficit and disability, and bone mineral density that was quantified by bilateral hip dual energy X-ray absorbimetry. Osteoporosis was defined as a T score below -2.5. Carotid ultrasound was used to classify plaques in non-hyperechoic (grade 1) and hyperechoic plaque (grade 2). RESULTS: We found a high prevalence of low bone mass density (BMD) in our patients (18 out of 49=36.7%), without relationship to the side of paresis. According to univariate analysis evidence of osteoporosis was correlated with age (p=0.05), score of Scandinavian Stroke Scale (p=0.01) and grade 2 plaque (p=0.01). According to multivariate analysis, there was a significant positive correlation between grade 2 plaques and osteoporosis (OR=6.58; 95% CI=1.57-27.54; p=0.01), which was stronger in women (OR=18.15; 95% CI=1.80-182.83; p=0.01). The percentage of intraplaque hyperechogenicity was inversely correlated with BMD (r=-0.411, p=0.016). CONCLUSION: Osteoporosis is highly prevalent in acute atherosclerotic stroke patients. Carotid hyperechoic plaque is an independent marker of osteoporosis.

Stump pressure and transcranial Doppler for predicting shunting in carotid endarterectomy.

OBJECTIVES: to compare stump pressure (SP) and transcranial Doppler (TCD) with neurologic monitoring during carotid endarterectomy (CEA). MATERIALS: one hundred and forty-seven CEAs performed under local anaesthesia. METHODS: neurologic monitoring and SP were performed in all cases, while mean velocity of the middle cerebral artery (mvMCA) by TCD was done in 140/147 (95%) cases. Shunts were applied in all cases on the basis of neurologic monitoring. The following haemodynamic criteria have been compared to neurologic monitoring: (a) <25 mmHg SP; (b) <50 mmHg SP; (c) < or =10 cm/s mvMCA after carotid occlusion; (d) > or =70 decrease of mvMCA after carotid occlusion. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated for each haemodynamic criterion. RESULTS: shunt was used in 18/147 (12.2%) cases. With regards to <25 mmHg SP, < or =50 mmHg SP, < or =10 cm/s mvMCA after carotid occlusion, and > or =70 decrease of mvMCA after carotid occlusion, sensitivity resulted 33, 89, 80 and 80%, respectively. Specificity resulted 96, 82, 97 and 96%, respectively. Positive predictive value resulted 55, 41, 75 and 71%, respectively. Negative predictive value 91, 98, 98 and 98%, respectively. Accuracy resulted 88, 76, 89 and 94%, respectively. CONCLUSIONS: none of the haemodynamic criteria by SP and TCD resulted absolutely reliable in predicting the need for carotid shunt.

Cerebral haemodynamic aspects of severe carotid stenosis: asymptomatic vs symptomatic.

OBJECTIVES: to compare cerebral haemodynamics in patients with asymptomatic and symptomatic severe (> or =70%) internal carotid artery (ICA) stenosis. METHODS: we assessed 195 consecutive patients, 116 with asymptomatic carotid stenosis (ACS) and 79 with symptomatic carotid stenosis (SCS). Using transcranial Doppler we assessed cerebral vasoreactivity (CVR) following acetazolamide test, the middle cerebral artery flow velocity ratio after/before carotid clamping (mv-MCA ratio), and the carotid back pressure (CBP) during crossclamping. RESULTS: no significant differences between the two groups were demonstrated regarding CVR (47 vs 39%), mv-MCA ratio (50 vs 52%), or CBP (36 vs 44 mmHg). However, in patients with contralateral ICA occlusion all three variables were significantly lower as compared to patients with patent contralateral ICA. Also patients who needed a shunt during surgery had significantly lower values of mv-MCA ratio and CBP. Patients who suffered peri-operative neurologic deficits (n=6; 3%) did not differ from patients who had an uneventful course. CONCLUSIONS: clinical state of ICA stenosis is independent of cerebral haemodynamics. Occluded contralateral ICA is more important for predicting cerebral ischaemia caused by carotid clamping. Finally, none of the haemodynamic parameters showed predictive value for peri-operative neurologic morbidity.

[Growth rate of abdominal aortic aneurysms. Ultrasounds study and clinical outcome]. / Espansione degli aneurismi dell'aorta addominale. Studio ecografico e outcome clinico.

BACKGROUND: The standard treatment for abdominal aortic aneurysms (AAA) >55 mm is actually represented by surgical repair mainly or by endovascular repair, in selected cases; conversely the debate is still open for those ranging 40-55 mm. These last and smaller aneurysms are usually followed-up by ultrasounds (US), in order to detect too fast expansions and to prevent sudden ruptures. Aim of this study is to present the results of the US follow-up of a series of asymptomatic AAAs and the correlation between expansion rate and associated risk factors. METHODS: All patients evaluated for an AAA between March 1991 and December 2000 were included and, according to the maximum diameters of the infrarenal aorta, were divided into 3 groups: A (26-29 mm), B (30-39 mm) and C (>39 mm). Groups A and B underwent US follow up at 6-month intervals, while group C underwent a complete preoperative evaluation. RESULTS: The mean follow up was 36+/-24 months for the entire series (225 AAA); the mean expansion rate was 1 mm/year for group A, <1.5 mm/year for group B for the first 5 years with a sharp increase (5 mm/year) in the following 2 years and 3 mm/year for group C up to 5 years. Among the associated risk factors, hypertension and smoking have confirmed their main role, independent from the initial diameter (p<0.01). Eight ruptures (3.8%) occurred in patients unsuitable for surgery or who refused it and in 7 cases they were lethal. The range between diagnosis and death (19-61 months) and the maximum size (38-93 mm) were absolutely unpredictable. The remaining 40 deaths were related to vascular diseases (MI and stroke 29.8%) or concurrent neoplasms (29.8%) mainly. The surgical treatment was carried out as elective repair on 45 patients (mortality rate 2.2%) and in emergency in 2 cases, both dead, with a mean interval from diagnosis to surgery of 28+/-17 months. CONCLUSIONS: Our results agree with the literature data concerning the dilatative trend and the risk factors and, according to these, elective repair in patients with AAA ranging 45-55 mm should be considered.

Can cerebral vasoreactivity predict cerebral tolerance to carotid clamping during carotid endarterectomy?

Cerebral vasoreactivity (CVR) was evaluated as a preoperative test in predicting cerebral tolerance to carotid clamping.A consecutive series of 115 carotid endarterectomy (CEA) cases were studied. Before surgical operation CVR was evaluated, by measuring the mean velocity of the middle cerebral artery (mv-MCA) using transcranial Doppler (TCD) at the basal condition and 20 min after intravenous administration of acetazolamide (1 g). CEA was performed under general anesthesia. TCD was used during surgery to evaluate mv-MCA and to calculate mv-MCA clamping/mv-MCA pre-clamping x100 ratio (mv-MCA%), which was used as the parameter to validate CVR.CVR did not correlate with mv-MCA% (r=0.22). There was no significant difference (P=0.09) between mean values of the non shunted subgroup and the shunted one.CVR does not seem to be suitable for evaluating cerebral tolerance to carotid clamping.

[Surgery of recurrent varices of the minor saphenous vein]. / Chirurgia delle varici recidive della vena piccola safena.

BACKGROUND: Investigation of the diagnostic and technical problems of redo surgery of the lesser saphenous vein for primary varicose veins. DESIGN: a retrospective study. SETTING: Section of Vascular Surgery in a University Hospital. PATIENTS: Fifteen lower extremities were operated upon (13 patients, 3 males and 10 females, ages ranging from 43 to 65 years with a mean of 53.2). INTERVENTIONS: Each case was assessed by clinical examination, duplex scanning and venography (ascending venography and/or varicography). Surgical procedure was carried out via a longitudinal approach over the popliteal region or the posterior aspect of the thigh. Each case presented with a stump of the lesser saphenous vein. MEASURES: Hemodynamic (correction of reflux of the lesser saphenous vein) and clinical (improvement of clinical state in the operated lower limb and complications) results were evaluated. RESULTS: Reflux at the ostium of the lesser saphenous vein was corrected in 15/15 (100%) cases. Clinical result was good in 15/15 (100%) cases. Postoperative edema was observed in 7/15 (46.7%) cases. Lesion of the common peroneal nerve with paresis of the foot dorsal flexion was found in 1/15 (6.7%) cases. Hypertrophic scar was observed in 4/15 (26.7%) cases. CONCLUSIONS: Redo surgery of the lesser saphenous vein is requested less frequently than other surgical procedures for superficial venous diseases. This surgery requires two essential features: a) accurate diagnosis of the lesser saphenous vein insufficiency; b) adequate surgical technique. For the former purpose, venography is a fundamental method of assessment. Surgical technique should be cautious and gentle. A longitudinal approach leads to a wide exposure of the structures in the popliteal fossa.