RESUMEN
BACKGROUND: Despite impressive improvements in the safety profile of Transcatheter aortic valve replacement (TAVR), the risk for peri-procedural stroke after TAVR has not declined substantially. In an effort to reduce periprocedural stroke, cerebral embolic protection (CEP) devices have been utilized but have yet to demonstrate benefit in all-comers. There is a paucity of data supporting the utilization of CEP in TAVR patients with an anticipated high risk for peri-procedural stroke. METHODS: The Transcatheter Aortic Valve Replacement In-Hospital Stroke (TASK) score is a clinical risk tool for predicting the in-hospital stroke risk of patients undergoing transfemoral TAVR. This score was used to identify high-risk patients and calculate the expected in-hospital stroke risk. This was a single-centre cohort study in all consecutive TAVR patients who had placement of CEP. The observed versus expected ratio for peri-procedural stroke was calculated. To obtain 95% credible intervals, we used 1000 bootstrapped samples of the original cohort sample size without replacement and recalculated the TASK predicted scores. RESULTS: The study included 103 patients. The median age was 83 (IQR 78,89). 63 were male (61.1%) and 45 (43.69%) had a history of previous Stroke or TIA. Two patients had an in-hospital stroke after TAVR (1.94%). The expected risk of in-hospital stroke based on the TASK score was 3.39% (95% CI 3.07-3.73). The observed versus expected ratio was 0.57 (95% CI 0.52-0.64). CONCLUSION: In this single-center study, we found that in patients undergoing TAVR with high stroke risk, CEP reduced the in-hospital stroke risk by 43% when compared with the risk-score predicted rate. CLINICAL TRIAL NUMBER: N/A.
Asunto(s)
Dispositivos de Protección Embólica , Accidente Cerebrovascular , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Masculino , Femenino , Anciano , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/instrumentación , Factores de Riesgo , Medición de Riesgo , Anciano de 80 o más Años , Accidente Cerebrovascular/prevención & control , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/epidemiología , Resultado del Tratamiento , Estenosis de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/fisiopatología , Factores de Tiempo , Embolia Intracraneal/prevención & control , Embolia Intracraneal/etiología , Embolia Intracraneal/epidemiología , Embolia Intracraneal/diagnóstico , Estudios Retrospectivos , Técnicas de Apoyo para la Decisión , Valor Predictivo de las PruebasRESUMEN
BACKGROUND: Stent-assisted carotid artery revascularization employing surgical cutdown for transcervical access and dynamic flow reversal (TCAR) is gaining popularity. TCAR, despite maximized intra-procedural cerebral protection, shows a marked excess of 30-day neurologic complications in symptomatic vs. asymptomatic stenoses. The TCAR conventional single-layer stent (free-cell area 5.89mm2) inability to seal embologenic lesions may be particularly relevant after the flow reversal neuroprotection is terminated. METHODS: We evaluated peri-procedural and 30-day major adverse cerebral and cardiac events (MACCE) of TCAR (ENROUTE, SilkRoad Medical) paired with MicroNET-covered neuroprotective stent (CGuard, InspireMD) in consecutive patients at elevated risk of complications with transfemoral/transradial filter-protected stenting (increased lesion-related and/or access-related risk). CGuard (MicroNET free cell area ≈0.02-0.03 mm2) has level-1 evidence for reducing intra- and abolishing post-procedural lesion-related cerebral embolism. RESULTS: One hundred and six increased-risk patients (age 72 [61-76] years, median [Q1-Q3]; 60.4% symptomatic, 49.1% diabetic, 36.8% women, 61.3% left-sided index lesion) were enrolled in three vascular surgery centers. Angiographic stenosis severity was 81 (75-91)%, lesion length 21 (15-26)mm, increased-risk lesional characteristics 87.7%. Study stent use was 100% (no other stent types). 74.5% lesions were predilated; post-dilatation rate was 90.6%. Flow reversal duration was 8 (5-11)min. One stroke (0.9%) occurred in an asymptomatic patient prior to establishing neuroprotection (index lesion disruption with the sheath insertion wire); there were no other peri-procedural MACCE. No further adverse events occurred by 30-days. 30-day stent patency was 100% with normal velocities and absence of any in-stent material by Duplex Doppler. CONCLUSIONS: Despite a high proportion of increased-risk lesions and clinically symptomatic patients in this study, TCAR employing the MicroNET-covered anti-embolic stent showed 30-day MACCE rate <1%. This suggests a clinical role for combining maximized intra-procedural prevention of cerebral embolism by dynamic flow reversal with anti-embolic stent prevention of peri- and post-procedural cerebral embolism (TOPGUARD NCT04547387).
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Estenosis Carotídea , Dispositivos de Protección Embólica , Embolia Intracraneal , Diseño de Prótesis , Stents , Humanos , Anciano , Femenino , Masculino , Estenosis Carotídea/cirugía , Estenosis Carotídea/fisiopatología , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/complicaciones , Persona de Mediana Edad , Resultado del Tratamiento , Embolia Intracraneal/prevención & control , Embolia Intracraneal/etiología , Factores de Tiempo , Factores de Riesgo , Circulación Cerebrovascular , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/efectos adversos , Estudios Prospectivos , Accidente Cerebrovascular/prevención & control , Accidente Cerebrovascular/etiologíaRESUMEN
BACKGROUND: The study aims to evaluate the association of proximal flow-inversion cerebral protection and MicroNet-covered CGuard stents in reducing early and late embolic events in carotid artery stenting procedures. METHODS: From 2018 to 2023, we performed 204 procedures in 180 patients with flow inversion cerebral protection and CGuard stents at the Vascular Surgery Unit of Sant'Eugenio Hospital in Rome. Cerebral protection was achieved with a Flow-Gate2 catheter connected to a peripheral vein. The tip balloon is inflated in the CCA to obtain an effective endoclamping, the pressure difference between the carotid bifurcation and the venous compartment ensures a constant back flow with wash-out in the venous compartment. Inclusion criteria were: life expectancy of >12 months, target lesions indicating treatment according to ESVS Guidelines, increased surgical risk due to comorbidities or anatomic issues. ECD follow-up was performed immediately postoperatively, at 30 days, 6 and 12 months, and subsequently annually. RESULTS: The treatment protocol was successfully implemented in 99% of cases. No major strokes occurred, while one minor stroke (0.5%) occurred within 8 hours of the procedure, regressing in the following months. One perioperative death (0.5%) due to cerebral hemorrhage occurred three hours after the procedure. All patients remained asymptomatic, with no short or medium-term neurological score deterioration. One hemodynamically significant restenosis (0.5%) was detected at the 6-month follow-up. All patients completed the 6 months follow-up, though 6 (3%) were lost at the 12-month appointment. CONCLUSIONS: Our prospective monocentric study has demonstrated the effectiveness and safety of the FlowGate2 flow inversion cerebral protection system in association with MicroNet covered CGuard stent.
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Estenosis Carotídea , Dispositivos de Protección Embólica , Diseño de Prótesis , Stents , Humanos , Femenino , Masculino , Anciano , Estenosis Carotídea/complicaciones , Estenosis Carotídea/fisiopatología , Estenosis Carotídea/cirugía , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/terapia , Resultado del Tratamiento , Factores de Tiempo , Circulación Cerebrovascular , Persona de Mediana Edad , Anciano de 80 o más Años , Factores de Riesgo , Ciudad de Roma , Angioplastia de Balón/efectos adversos , Angioplastia de Balón/instrumentación , Embolia Intracraneal/prevención & control , Embolia Intracraneal/etiología , Estudios ProspectivosAsunto(s)
Fibrilación Atrial , Ablación por Catéter , Criocirugía , Embolia Intracraneal , Humanos , Fibrilación Atrial/cirugía , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/fisiopatología , Criocirugía/efectos adversos , Ablación por Catéter/efectos adversos , Estudios Prospectivos , Incidencia , Embolia Intracraneal/etiología , Embolia Intracraneal/epidemiología , Resultado del Tratamiento , Masculino , Femenino , Factores de Riesgo , Persona de Mediana Edad , Anciano , Factores de TiempoRESUMEN
BACKGROUND: This study aimed to clarify the characteristics and survival prediction value of transcranial Doppler microembolic signals (MES) in patients with acute cerebral infarction and active cancer. METHODS AND RESULTS: Between 2017 and 2022, 1089 cases of acute cerebral infarction were recorded within 7 days of disease onset. Among them, transcranial Doppler was successful in 33 patients who had active cancer, and these data were analyzed in this study. The primary outcomes were stroke recurrence and mortality at 3 months. The study population had the following characteristics [median (interquartile range)]: age, 70 years (63-78); body mass index, 21.6 (20-24), National Institutes of Health Stroke Scale 3 (1-6), and modified Rankin Scale score at discharge 1 (1-4). The most common cancer types were lung (24%), pancreatic (24%), and intestinal (18%). MES was present in 16 of 33 patients (48.5%). The presence and number of MES were significantly associated with the levels of D-dimer (P <0.001) and C-reactive protein (P=0.012). Moreover, the presence of MES was associated with multiple ischemic lesions and the 3-territory sign on magnetic resonance imaging. Of the 33 patients, 9 died at 3 months, and 1 had stroke recurrence. On Cox multivariate analysis, using the MES-negative group as a reference, the presence of MES was significantly associated with all-cause death (adjusted hazard ratio, 12.19 [95% CI, 1.45-216.85]; P=0.020). CONCLUSIONS: In patients with acute ischemic stroke and active cancer, the presence of MES was associated with D-dimer and C-reactive protein levels and multiple and 3-territory ischemic lesions, and was predictive of short-term survival.
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Embolia Intracraneal , Accidente Cerebrovascular Isquémico , Neoplasias , Ultrasonografía Doppler Transcraneal , Humanos , Masculino , Femenino , Anciano , Ultrasonografía Doppler Transcraneal/métodos , Persona de Mediana Edad , Accidente Cerebrovascular Isquémico/mortalidad , Accidente Cerebrovascular Isquémico/diagnóstico por imagen , Neoplasias/mortalidad , Neoplasias/complicaciones , Neoplasias/diagnóstico por imagen , Embolia Intracraneal/mortalidad , Embolia Intracraneal/diagnóstico por imagen , Embolia Intracraneal/etiología , Factores de Tiempo , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Factores de Riesgo , Pronóstico , Medición de Riesgo , RecurrenciaRESUMEN
Introduction: Cerebral gas embolism is an unusual but extremely serious condition that occurs when air is introduced into the arterial or venous circulation of the brain. Although rare, it can lead to significant neurological deficits and even the death of the patient. Clinical Case: 76-year-old patient with pre-existing diffuse interstitial lung disease, who experienced a massive stroke due to spontaneous pneumomediastinum. Her presentation included confusion, seizures, and motor weakness. Imaging tests revealed air bubbles in the cerebral sulci and hypodense areas in the cerebellum and parietooccipitals. In addition, pneumothorax and air in the upper mediastinum were noted on chest radiographs and chest CT scan. Despite therapeutic measures such as hyperbaric oxygen, the patient unfortunately died due to multiple organ failure. Discussion: The diagnosis of cerebral gas embolism generally involves performing a cerebral computed tomography, which is highly sensitive for detecting the presence of air in the cerebral vessels. Management includes monitoring of vital and neurological signs, as well as specific measures such as airway closure, venous catheter aspiration, Trendelenburg positioning, and hyperbaric oxygen. Conclusion: Cerebral gas embolism is a potentially fatal condition that requires a brain computed tomography for diagnosis and it is vitally important to know the prevention measures to avoid the appearance of this complication and also to know the general measures to adopt when it occurs.
Introducción: La embolia gaseosa cerebral es una afección inusual pero extremadamente grave que se produce cuando se introduce aire en la circulación arterial o venosa del cerebro. Aunque poco común, puede derivar en déficits neurológicos significativos e incluso la muerte del paciente. Caso Clínico: Paciente de 76 años con una enfermedad pulmonar intersticial difusa preexistente, que experimentó un ictus masivo debido a un neumomediastino espontáneo. Su presentación incluyó confusión, convulsiones y debilidad motora. Las pruebas de imagen revelaron burbujas de aire en los surcos cerebrales y áreas hipodensas en el cerebelo y parietooccipitales. Además, se observó neumotórax y aire en el mediastino superior en las radiografías de tórax y la tomografía torácica. A pesar de las medidas terapéuticas como el oxígeno hiperbárico, la paciente lamentablemente falleció debido al fallo multiorgánico. Discusión: El diagnóstico de embolia gaseosa cerebral generalmente implica la realización de una tomografía computarizada cerebral, que es altamente sensible para detectar la presencia de aire en los vasos cerebrales. El manejo incluye el control de las constantes vitales y neurológicas, así como medidas específicas como cierre de la entrada de aire, aspiración de catéteres venosos, posicionamiento de Trendelenburg y oxígeno hiperbárico. Conclusión: La embolia gaseosa cerebral es una afección potencialmente mortal que requiere una tomografía computarizada cerebral para el diagnóstico y de vital importancia conocer las medidas de prevención para evitar la aparición de esta complicación y así mismo conocer las medidas generales a adoptar cuando ésta se presenta.
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Embolia Aérea , Embolia Intracraneal , Enfermedades Pulmonares Intersticiales , Humanos , Masculino , Embolia Aérea/etiología , Embolia Aérea/diagnóstico por imagen , Embolia Aérea/terapia , Anciano , Resultado Fatal , Enfermedades Pulmonares Intersticiales/diagnóstico por imagen , Enfermedades Pulmonares Intersticiales/etiología , Enfermedades Pulmonares Intersticiales/complicaciones , Embolia Intracraneal/etiología , Embolia Intracraneal/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Oxigenoterapia HiperbáricaAsunto(s)
Dispositivos de Protección Embólica , Embolia Intracraneal , Humanos , Embolia Intracraneal/prevención & control , Embolia Intracraneal/etiología , Embolia Intracraneal/diagnóstico por imagen , Resultado del Tratamiento , Factores de Riesgo , Medición de Riesgo , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/efectos adversos , Diseño de PrótesisAsunto(s)
Dispositivos de Protección Embólica , Embolia Intracraneal , Humanos , Embolia Intracraneal/prevención & control , Embolia Intracraneal/etiología , Embolia Intracraneal/diagnóstico por imagen , Resultado del Tratamiento , Factores de Riesgo , Medición de Riesgo , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/efectos adversosRESUMEN
BACKGROUND: Surgery or fibrinolysis is the currently available evidence-based treatment for obstructive mechanical valve thrombus. We reported the feasibility and short-term outcomes of percutaneous transcatheter therapy with cerebral embolic protection. Mid- and long-term outcomes remain unknown. METHODS: From 2020 to 2023, 24 patients underwent percutaneous transcatheter release of stuck leaflets with cerebral embolic protection for obstructive mitral mechanical valve thrombus. The indications for the transcatheter therapy were failed fibrinolysis, contraindications for fibrinolysis, not willing for fibrinolysis, or high risk for surgery. The study participants were followed up for a median period of 344.50 (65.00-953.75) days. RESULTS: Technical success was achieved in 91.67% (n=22) of procedures. During the follow-up, 12.50% (n=3) all-cause death, 4.17% (n=1) stroke, and 16.67% (n=4) recurrence were seen. The mean survival time free from death was 1101.48 (95% CI, 929.49-1273.47) days, stroke was 1211.38 (95% CI, 1110.40-1312.35) days, and recurrence was 907.71 (95% CI, 760.20-1055.21) days. CONCLUSIONS: Transcatheter release of the stuck mitral mechanical valve with cerebral embolic protection is an alternative therapy with promising mid-term outcomes where surgery or fibrinolysis is not possible or in failed fibrinolysis subsets.
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Cateterismo Cardíaco , Dispositivos de Protección Embólica , Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Embolia Intracraneal , Válvula Mitral , Humanos , Masculino , Femenino , Válvula Mitral/cirugía , Válvula Mitral/fisiopatología , Válvula Mitral/diagnóstico por imagen , Anciano , Embolia Intracraneal/prevención & control , Embolia Intracraneal/etiología , Embolia Intracraneal/mortalidad , Embolia Intracraneal/diagnóstico por imagen , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/instrumentación , Cateterismo Cardíaco/mortalidad , Persona de Mediana Edad , Factores de Tiempo , Factores de Riesgo , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Resultado del Tratamiento , Estudios Retrospectivos , Anciano de 80 o más Años , Recurrencia , Diseño de Prótesis , Trombosis/prevención & control , Trombosis/etiología , Trombosis/mortalidad , Trombosis/diagnóstico por imagen , Estudios de Factibilidad , Falla de Prótesis , Medición de RiesgoRESUMEN
BACKGROUND: Although rare, paradoxical embolism sometimes occurs with patent ductus arteriosus (PDA). This study presents a case of PDA-associated paradoxical embolism with acute ischemic stroke (AIS) and pulmonary embolism (PE) following thoracoscopic surgery. CASE PRESENTATION: A 65-year-old woman developed acute-onset aphasia and right hemiparesis on the third day following thoracoscopic resection for a right lung tumor. Brain magnetic resonance imaging revealed multiple infarcts, and lower extremity venous Doppler ultrasound revealed deep vein thrombosis. The patient subsequently developed dyspnea, tachycardia, and hypoxemia. PE was confirmed by percutaneous transfemoral venous selective pulmonary angiography, which meanwhile demonstrated a PDA lesion. The patient, after receiving catheter-directed thrombolysis and inferior vena cava filter placement, improved in both neurological and respiratory status. CONCLUSION: For an uncommon but potentially fatal case with PDA-induced paradoxical embolism causing AIS and PE, early recognition and treatment are vital. Further studies are warranted to determine the optimal management and prognosis of patients with PDA-related embolic events.
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Conducto Arterioso Permeable , Embolia Intracraneal , Embolia Pulmonar , Humanos , Femenino , Embolia Pulmonar/etiología , Anciano , Conducto Arterioso Permeable/complicaciones , Conducto Arterioso Permeable/cirugía , Embolia Intracraneal/etiología , Embolia Paradójica/etiología , Imagen por Resonancia MagnéticaRESUMEN
BACKGROUND: Recent randomized controlled trials (RCTs) have demonstrated similar outcomes in terms of ischemic stroke incidence after carotid endarterectomy (CEA) or carotid artery stenting (CAS) in asymptomatic carotid disease, while CEA seems to be the first option for symptomatic carotid disease. The aim of this meta-analysis is to assess the incidence of silent cerebral microembolization detected by magnetic resonance imaging (MRI) following these procedures. METHODS: A systematic search was conducted using PubMed, Scopus, and Cochrane databases, including comparative studies involving symptomatic or asymptomatic patients undergoing either CEA or CAS and reporting on new cerebral ischemic lesions in postoperative MRI. The primary outcome was the newly detected cerebral ischemic lesions. Pooled effect estimates for all outcomes were calculated using the random-effects model. Prespecified random effects metaregression and subgroup analysis were conducted to examine the impact of moderator variables on the presence of new cerebral ischemic lesions. RESULTS: 25 studies reporting on a total of 1827 CEA and 1500 CAS interventions fulfilled the eligibility criteria. The incidence of new cerebral ischemic lesions was significantly lower after CEA compared to CAS, regardless of the time of MRI assessment (first 24 hours; OR: 0.33, 95% CI: 0.17-0.64, P < 0.001), (the first 72 hours, OR: 0.25, 95% CI 0.18-0.36, P < 0.001), (generally within a week after the operation; OR: 0.24, 95% CI: 0.17-0.34, P < 0.001). Also, the rate of stroke (OR: 0.38, 95% CI: 0.23-0.63, P < 0.001) and the presence of contralateral new cerebral ischemic lesions (OR: 0.16, 95% CI 0.08-0.32, P < 0.001) were less frequent after CEA. Subgroup analysis based on the study design and the use of embolic protection device during CAS showed consistently lower rates of new lesions after CEA. CONCLUSIONS: CEA demonstrates significant lower rates of new silent cerebral microembolization, as detected by MRI in postoperative period compared with CAS.
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Endarterectomía Carotidea , Procedimientos Endovasculares , Imagen por Resonancia Magnética , Valor Predictivo de las Pruebas , Stents , Humanos , Endarterectomía Carotidea/efectos adversos , Resultado del Tratamiento , Factores de Riesgo , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Factores de Tiempo , Anciano , Femenino , Masculino , Isquemia Encefálica/etiología , Isquemia Encefálica/diagnóstico por imagen , Isquemia Encefálica/prevención & control , Incidencia , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/terapia , Estenosis Carotídea/cirugía , Persona de Mediana Edad , Medición de Riesgo , Enfermedades de las Arterias Carótidas/diagnóstico por imagen , Enfermedades de las Arterias Carótidas/cirugía , Enfermedades de las Arterias Carótidas/terapia , Embolia Intracraneal/etiología , Embolia Intracraneal/diagnóstico por imagen , Embolia Intracraneal/prevención & control , Enfermedades AsintomáticasAsunto(s)
Embolia Aérea , Embolia Intracraneal , Neoplasias Pulmonares , Humanos , Ablación por Catéter/efectos adversos , Embolia Aérea/etiología , Embolia Aérea/diagnóstico por imagen , Embolia Intracraneal/etiología , Neoplasias Pulmonares/cirugía , Complicaciones Posoperatorias/etiología , Accidente Cerebrovascular/etiología , Tomografía Computarizada por Rayos XRESUMEN
INTRODUCTION: Calcified arterial cerebral embolism is a rare occurrence among large and medium vessel occlusions causing ischemic stroke and its diagnosis and treatment is a challenge. The sources of calcified embolism might be a calcific atheroma from the aortic arch and carotid artery, but also heart valve disease has been reported in the literature. Calcified embolism is frequently simultaneous on multiple vascular territories. The prognosis of patients is usually poor, including patients treated by using endovascular thrombectomy (EVT) and this diagnosis could be easily missed in the acute phase. In addition, the optimal secondary prevention has not been yet fully stated. METHODS: We are presenting two cases of acute stroke due to calcified embolism in the middle cerebral artery (MCA) coming from a complicated carotid atheroma, non-stenosing in the first case (a 49 years old man) and stenosing in the second case (a 71 years old man) without clinical indications to intravenous thrombolysis and/or EVT, extensively investigated in the acute phase and followed-up for over 12 months with a favorable clinical course and the persisting steno-occlusion in the involved MCA. In both cases, antiplatelet treatment and targeting of vascular risk factors were done without recurrences in the follow-up period. DISCUSSION: Cerebral calcified embolism has been reported in 5.9% of cases of acute ischemic stroke in a single center series and only in 1.2% of a large retrospective cohort of EVT-treated patients. In both series the prognosis was poor and only one third of EVT-treated patients had functional independence at 3-months follow-up. The natural history of these subtype of ischemic stroke is relatively poorly understood and both etiological diagnosis and treatment have not yet defined. It is possible that some cases might be underdiagnosed and underreported. CONCLUSIONS: Calcified cerebral embolism is a rare cause of stroke, but it is largely underreported and both acute phase and secondary preventive treatment have to be defined.
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Embolia Intracraneal , Humanos , Masculino , Persona de Mediana Edad , Anciano , Embolia Intracraneal/etiología , Embolia Intracraneal/diagnóstico por imagen , Calcinosis/complicaciones , Calcinosis/diagnóstico por imagen , Infarto de la Arteria Cerebral Media/diagnóstico por imagen , Infarto de la Arteria Cerebral Media/complicacionesRESUMEN
BACKGROUND: Careful selection of patients for carotid stenting is necessary. We suggest that patients with a shaggy aorta syndrome may be at higher risk for perioperative embolic complications. METHODS: The study is a retrospective subanalysis of the SIBERIA Trial. We included 72 patients undergoing transfemoral carotid artery stenting. Patients were monitored during the procedures using multifrequency transcranial Doppler with embolus detection and differentiation. Pre- and postprocedural (2 and 30 days) cerebral diffusion-weighted cerebral MRIs were performed. RESULTS: Forty-six patients had shaggy aorta syndrome. Intraoperative embolisms were recorded in 82.6% and 46.1% of patients with and without shaggy aorta syndrome, respectively (P=0.001). New asymptomatic ischemic brain lesions in the postoperative period occurred in 78.3% and in 26.9% of patients with and without shaggy aorta syndrome, respectively (P<0.001). There were no cases of stroke within 2 days in both groups. 3 (6.5%) cases of stroke within 30 days after the procedure were observed only in patients with shaggy aorta syndrome. There were no cases of contralateral stroke. Shaggy aorta syndrome (OR 5.54 [1.83:16.7], P=0.001) and aortic arch ulceration (OR 6.67 [1.19: 37.3], P=0.02) were independently associated with cerebral embolism. Shaggy aorta syndrome (OR 9.77 [3.14-30.37], P<0.001) and aortic arch ulceration (OR 12.9 [2.3: 72.8], P=0.003) were independently associated with ipsilateral new asymptomatic ischemic brain lesions. CONCLUSIONS: Shaggy aorta syndrome and aortic arch ulceration significantly increase the odds of intraoperative embolism and new asymptomatic ischemic brain lesions. Carotid endarterectomy or transcervical carotid stent should be selected in patients with shaggy aorta syndrome.
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Embolia Intracraneal , Stents , Humanos , Embolia Intracraneal/etiología , Embolia Intracraneal/diagnóstico por imagen , Masculino , Femenino , Stents/efectos adversos , Anciano , Estudios Retrospectivos , Persona de Mediana Edad , Factores de Riesgo , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades de la Aorta/complicaciones , Imagen de Difusión por Resonancia Magnética , Complicaciones Intraoperatorias/epidemiología , Resultado del Tratamiento , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/complicaciones , Estenosis Carotídea/cirugía , Ultrasonografía Doppler Transcraneal , Síndrome , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Anciano de 80 o más AñosRESUMEN
BACKGROUND: Cerebral fat embolism (CFE) is a rare but potentially fatal complication that can occur after long bone fractures. It represents one subcategory of fat embolisms (FE). Diagnosing CFE can be challenging due to its variable and nonspecific clinical manifestations. We report a case of CFE initially presenting with turbid urine, highlighting an often neglected sign. CASE PRESENTATION: A 69-year-old male was admitted after a traffic accident resulting in bilateral femoral fractures. Sixteen hours post-admission, grossly turbid urine was noted but received no special attention. Four hours later, he developed rapid deterioration of consciousness and respiratory distress. Neurological examination revealed increased upper limb muscle tone and absent voluntary movements of lower limbs. Brain MRI demonstrated a 'starfield pattern' of diffuse punctate lesions, pathognomonic for CFE. Urine microscopy confirmed abundant fat droplets. Supportive treatment and fracture fixation were performed. The patient regained consciousness after 3 months but had residual dysphasia and limb dyskinesia. CONCLUSION: CFE can present with isolated lipiduria preceding overt neurological or respiratory manifestations. Heightened awareness of this subtle sign in high-risk patients is crucial for early diagnosis and intervention. Prompt urine screening and neuroimaging should be considered when gross lipiduria occurs after long bone fractures.
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Embolia Grasa , Embolia Intracraneal , Humanos , Masculino , Embolia Grasa/diagnóstico , Embolia Grasa/etiología , Anciano , Embolia Intracraneal/diagnóstico , Embolia Intracraneal/etiología , Fracturas del Fémur/diagnóstico , Imagen por Resonancia Magnética , Accidentes de TránsitoRESUMEN
BACKGROUND: Carotid artery stenting (CAS) has become a cornerstone of carotid revascularization for stroke prevention. Despite the advantages of CAS, large-scale randomized trials involving prior (single-layer) first generation stents (FGS) demonstrated a higher risk of periprocedural cerebrovascular events compared to surgery. Dual-layer mesh-covered stents (DLSs) showed promising results in terms of 30-day embolic events in initial studies; larger-scale evidence is accumulating. This study aims to evaluate 30-day clinical efficacy of DLS against a closed-cell stent, based on large-volume data. METHODS: The study center is part of the Italian National Outcomes Evaluation Program (PNE). CAS procedures performed between November 2017 and September 2023 were eneterd into a prospectively collected database. Our The primary endpoint was survival free of death, stroke, and myocardial infarction (MI) at 30 days. In addition, technical success and periprocedural major adverse clinical event rate (with a focus on stroke) were also evaluated. RESULTS: Over a total of 1101 CAS procedures (745 males; mean age 79±7.8 years), 48.6% were symptomatic. Majority (80.2%) were treated with DLSs. Technical success was achieved in 98.9%. The FGSs group showed a significantly higher peri-procedural stroke rate when compared with CGuard and Roadsaver DLS: 4.59% vs. 1.18% vs. 2.63% (P=0.008); minor stroke rates were 4.13% vs. 0.83% and 0% P=0.01). The cumulative stroke, MI and death - free survival at 30 days was 97.46%. A statistically significant higher cumulative 30-day death/stroke/MI rate occurred in FGSs-treated patients compared to the CGuard and Roadsaver DLS-treated (6.42% vs. 1.42% and 2.63%, P=0.001). CONCLUSIONS: The use of DLS in patients undergoing CAS in our large-volume center showed a high technical success rate and minimal cerebral embolic complications by 30 days. High volumes and an experienced interventional team may contribute to these favorable outcomes.
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Estenosis Carotídea , Hospitales de Alto Volumen , Diseño de Prótesis , Stents , Humanos , Masculino , Anciano , Femenino , Factores de Tiempo , Anciano de 80 o más Años , Factores de Riesgo , Estenosis Carotídea/complicaciones , Estenosis Carotídea/mortalidad , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/terapia , Resultado del Tratamiento , Italia , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Bases de Datos Factuales , Infarto del Miocardio/etiología , Infarto del Miocardio/prevención & control , Dispositivos de Protección Embólica , Estudios Retrospectivos , Accidente Cerebrovascular/prevención & control , Accidente Cerebrovascular/etiología , Medición de Riesgo , Embolia Intracraneal/prevención & control , Embolia Intracraneal/etiología , Radiografía IntervencionalRESUMEN
OBJECTIVE: To assess the utility of combined neutrophil-to-lymphocyte ratio (NLR) and D-dimer detection in determining the severity and short-term prognosis of acute cardiogenic cerebral embolism (ACCE) in older adults. METHODS: We selected 202 elderly non-valvular atrial fibrillation patients hospitalized at the Third Affiliated Hospital of Anhui Medical University from April 1, 2020, to April 1, 2023. They were divided into an observation group (69 cases combined with ACCE) and a control group (133 cases with non-valvular atrial fibrillation alone) based on whether acute cardioembolic cerebral embolism occurred. According to the National Institutes of Health Stroke Scale (NIHSS), the observation group was divided into a mild cerebral infarction group (MICI group), a moderate cerebral infarction group (MOCI group), and a severe cerebral infarction group (SCI group), with 26 cases, 29 cases, and 14 cases, respectively. According to the modified Rankin scale (mRS), after 3 months, 30 cases were divided into the good prognosis group and 39 cases were divided into the poor prognosis group. We detected and compared the differences in D-dimer and NLR levels among different groups of patients, as well as differences in some important laboratory indicators. Logistic regression analysis was used to identify factors influencing the short-term prognosis of patients with acute cardioembolic cerebral infarction, and ROC curves were plotted to evaluate the value of D-dimer and NLR in predicting the short-term prognosis of patients with acute cardioembolic cerebral infarction. RESULTS: The levels of D-dimer and NLR in peripheral blood in SCI group [1.82 (0.58-6.71) mg/l, 4.55 (3.14,7.21)] were higher than those in MOCI group [1.16 (0.65-1.90) mg/l, 3.84 (2.31,6.68)] and MICI group [0.53 (0.32-0.90) mg/l, 2.46 (2.09-3.79)]. The difference between groups was statistically significant (P < 0.05). Logistic regression analysis showed that D-dimer and NLR were independent risk factors for poor prognosis in patients with acute cardiogenic cerebral embolism (OR values were 1.772 and 1.603, and 95 %CI were 1.060-2.963 and 1.100-2.338, respectively, both P < 0.05). The AUC for the prediction of poor prognosis in acute cardioembolic stroke by combining D-dimer and NLR was 0.812 [95 % CI: 0.710-0.914], higher than the individual detections of D-dimer at 0.756 [95% CI: 0.642-0.869] and NLR at 0.733 [95 % CI: 0.613-0.854]. CONCLUSION: Peripheral blood D-dimer combined with NLR detection is helpful for the risk stratification and short-term prognosis assessment of patients with acute cardiogenic cerebral embolism. Clinical detection is of great significance for the prevention and monitoring of disease development.
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Fibrilación Atrial , Biomarcadores , Productos de Degradación de Fibrina-Fibrinógeno , Linfocitos , Neutrófilos , Valor Predictivo de las Pruebas , Índice de Severidad de la Enfermedad , Humanos , Productos de Degradación de Fibrina-Fibrinógeno/análisis , Masculino , Anciano , Femenino , Pronóstico , Biomarcadores/sangre , Anciano de 80 o más Años , Recuento de Linfocitos , Factores de Tiempo , Factores de Riesgo , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/sangre , Fibrilación Atrial/complicaciones , Estudios Retrospectivos , Medición de Riesgo , Embolia Intracraneal/sangre , Embolia Intracraneal/diagnóstico , Embolia Intracraneal/etiología , Factores de Edad , Evaluación de la DiscapacidadRESUMEN
The superior thyroid cornu (STC) is a normal anatomic structure that forms part of the thyroid cartilage. Here, we report a patient with unusually elongated and ossified STC that might result in recurrent cerebral embolisms. During a second endovascular therapy for recurrent middle cerebral artery embolism, a segment with an irregular filling defect was noted in the internal carotid artery (ICA), at the C1 level. This defect was unnoticed during the initial endovascular procedure. Three-dimensional computed tomography angiography performed after the second endovascular procedure revealed an ICA segment located between the STC and C1 with a tortuous course and irregular wall of the ICA. Therefore, we assumed that STC compression of the ICA could have resulted in thrombus formation at the site and consequent cerebral embolism. The STC should be considered a structure responsible for cerebral embolism. Careful evaluation of the entire ICA course is imperative prior to performing an endovascular thrombectomy for acute embolic occlusion of the middle cerebral artery.
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Angiografía por Tomografía Computarizada , Embolia Intracraneal , Humanos , Embolia Intracraneal/etiología , Embolia Intracraneal/diagnóstico por imagen , Arteria Carótida Interna/anomalías , Arteria Carótida Interna/diagnóstico por imagen , Recurrencia , Imagenología Tridimensional , Glándula Tiroides/diagnóstico por imagen , Masculino , Procedimientos Endovasculares/métodos , Trombectomía/métodos , Femenino , Persona de Mediana Edad , Variación Anatómica , AncianoRESUMEN
PURPOSE OF REVIEW: Transcatheter aortic valve replacement (TAVR) has been a revolutionary therapy in the treatment of aortic valve stenosis. The risk of stroke associated with TAVR has decreased significantly since its introduction; however, it remains a devastating complication when it does occur. RECENT FINDINGS: Many of the strokes associated with TAVR occur peri-procedurally and are thought to be due to embolic debris entering the cerebrovascular circulation. A number of different cerebral embolic protection devices (CEPD) have been developed and are in various stages of testing and use. The results from clinical trials evaluating the role for CEPD to reduce the risk of stroke have been mixed. As a result, their uptake has been very heterogeneous. This review provides a summary of the diverse CEPD devices available for use and outlines the clinical evidence available to date.