Progression of carotid near-occlusion to complete occlusion: related factors and clinical implications.

BACKGROUND: The clinical consequences and factors related to the progression from a carotid near-occlusion (CNO) to a complete occlusion are not well established. Our aim is to describe the rate, predictive factors and clinical implications of the progression to complete carotid occlusion (PCCO) in a population of patients with symptomatic CNO. METHODS: We conducted a multicenter, nationwide, prospective study from January 2010 to May 2016. Patients with angiography-confirmed CNO were included. We collected information on demographic data, clinical manifestations, radiological and hemodynamic findings, and treatment modalities. A 24 month carotid-imaging follow-up of the CNO was performed. RESULTS: 141 patients were included in the study, and carotid-imaging follow-up was performed in 122 patients. PCCO occurred in 40 patients (32.8%), and was more frequent in medically-treated patients (34 out of 61; 55.7%) compared with patients treated with revascularization (6 out of 61; 9.8%) (p<0.001). 7 of the 40 patients with PCCO (17.5%) suffered ipsilateral symptoms. Factors independently related with PCCO in the multivariate analysis were: age ≥75 years (OR 2.93, 95% CI 1.05 to 8.13), revascularization (OR 0.07, 95% CI 0.02 to 0.20), and collateral circulation through the ipsilateral ophthalmic artery (OR 3.25, 95% CI 1.01 to 10.48). CONCLUSIONS: PCCO occurred within 24 months in more than half of the patients under medical treatment. Most episodes of PCCO were not associated with ipsilateral symptoms. Revascularization reduces the risk of PCCO.

Early risk of recurrent stroke in patients with symptomatic carotid near-occlusion: Results from CAOS, a multicenter registry study.

Background The risk of recurrent stroke among patients with symptomatic carotid near-occlusion is not well established, and management of the condition remains controversial. Symptomatic carotid near-occlusion with full collapse has been identified as a strong predictor of early recurrence. We aimed to analyze the 90-day risk of recurrent ipsilateral ischemic stroke in medically treated patients with symptomatic carotid near-occlusion. Methods We performed a multicenter, nationwide, prospective study from January 2010 to May 2016. Patients with angiography-confirmed symptomatic carotid near-occlusion were included. The primary endpoint was ipsilateral ischemic stroke or transient ischemic attack (TIA) within 90 days after the presenting event. For this analysis, patients who underwent revascularization within 90 days after stroke were excluded. Results The study population comprised 141 patients from 17 Spanish centers; 83 patients were treated medically. Primary endpoint occurred in eight patients, resulting in a cumulative rate of 10.6% (95% CI, 3.7-17.5). Previous history of stroke or transient ischemic attack was identified as an independent predictor for recurrence in the multivariate Cox regression analysis (HR, 4.37 [95% CI, 1.05-18.18]; p = 0.043), while the presence of full collapse was not associated with an increased risk (HR, 0.81 [95% CI, 0.17-3.92]; p = 0.793). The risk of recurrence was also not affected by the presence of significant stenosis or occlusion of the contralateral carotid artery, or by the collateral circulation. Conclusions Patients with symptomatic carotid near-occlusion seem to have an increased risk of early ipsilateral recurrent stroke. Our results contrast with the low risk of symptomatic carotid near-occlusion reported to date. Full collapse did not increase the risk of recurrent stroke in our study.

Circulating MicroRNAs as Novel Biomarkers of Stenosis Progression in Asymptomatic Carotid Stenosis.

BACKGROUND AND PURPOSE: Progression of asymptomatic carotid artery stenosis (ACAS) in patients with >50% luminal narrowing is considered a potential risk factor for ischemic stroke; however, subclinical molecular biomarkers of ACAS progression are lacking. Recent studies suggest a regulatory function for several microRNAs (miRNAs) on the evolution of carotid plaque, but its role in ACAS progression is mostly unknown. The aim of our study was to investigate a wide miRNA panel in peripheral blood exosomes from patients with ACAS to associate circulating miRNA expression profiles with stenosis progression. METHODS: The study included 60 patients with ACAS carrying >50% luminal narrowing. First, miRNA expression profiles of circulating exosomes were determined by Affymetrix microarrays from plasma samples of 16 patients from the cohort. Second, those miRNAs among the most differentially expressed in patients with ACAS progression were quantified by real-time polymerase chain reaction in a separate replication cohort of 39 subjects within the patient sample. RESULTS: Our results showed that ACAS progression was associated with development of stroke. MiR-199b-3p, miR-27b-3p, miR-130a-3p, miR-221-3p, and miR-24-3p presented significant higher expression in those patients with ACAS progression. CONCLUSIONS: In conclusion, our study supports that specific circulating miRNA expression profiles could provide a new tool that complements the monitoring of ACAS progression, improving therapeutic approaches to prevent ischemic stroke.

Short- and long-term outcomes in non-aneurysmal non-perimesencephalic subarachnoid hemorrhage.

OBJECTIVE: Our aim was to assess the short- and long-term prognosis in patients suffering from non-aneurysmal non-perimesencephalic SAH (Na-NPM-SAH). METHODS: Based on admission CT-scan, SAH was categorized as perimesencephalic (PM) or non-perimesencephalic (NPM). Based on digital subtraction angiography (DSA) results, patients were classified as normal DSA (Na-SAH) or aneurysmal SAH (aSAH). Between 1997 and 2010, 67 of 571 patients with non-traumatic SAH (11.7%) suffered from non-aneurysmal non-perimesencephalic SAH. Retrospective analyses of the 67 patients were undertaken, and compared with the aneurysmal SAH group. Long-term follow-up was assessed. RESULTS: The cohort consisted of 67 Na-NPM-SAH patients, mean age 54.8 years (range: 21-84), 56.7% male. Acute phase: 10.4% mortality and 3% rebleeding (two patients) during the acute phase. Long-term: extensive follow-up was possible in all except one of the survivors at discharge. Mortality was 6.6% during the 510 patient-years follow-up period (median follow-up time per patient, 8.95 years); rebleeding rate was 0-1.6%. An aneurysmal source was found in 13% of patients who underwent a second angiography. Aneurysmal SAH: 312 patients, with confirmed aneurysm by angiography. The mortality rate for Na-NPM-SAH during the acute phase was 10.4%, vs. 20% for aneurysmal SAH in the general database, p = 0.049. DISCUSSION: Na-NPM-SAH patients without an identifiable bleeding source on initial angiography might have a more benign short- and long-term prognosis than aneurysmal SAH patients. Our study confirms an important diagnostic advantage of a second arteriography. Still, despite the major concern of an undetected aneurysm, the long-term rebleeding rate was low in this subgroup of patients.

Characterisation of DWI-MRI confirmed cerebral infarcts in patients with subarachnoid haemorrhage and their association with MMP-9 levels.

OBJECTIVES: It has been suggested that metalloproteinase-9 (MMP-9) could predict the onset of cerebral vasospasm after subarachnoidal haemorrhage (SAH). The aim of this study was to analyse, in patients with SAH, the difference between patients with MRI ischaemic infarcts and patients without, and to investigate the role of metalloproteases as a prognostic factor for ischaemic infarcts. METHODS: Sixty eight consecutive patients with SAH and diffusion-weighted magnetic resonance imaging (DWI-MRI) done 3 weeks after SAH. We define two groups, with and without DWI-MRI infarcts. Blood samples were taken at entry, 3 days and 1 week MMP-9 was determined through ELISA method. RESULTS: Forty per cent were male, with a mean age of 54 ± 14 years. Twenty five patients, 36.8%, had DWI-MRI infarcts; in patients with MRI infarcts, SAH was more severe (Fisher = 4 52 vs 25.6%, P = 0.037), with more morbi-mortality (Rankin>3 48 vs 18.6%, P = 0.014), and more symptomatic vasospasm (28 vs 7%, P = 0.031). Levels of MMP-9 were higher than controls, but there were no significant differences between patients with and without infarcts (first determination no infarcts 39.40 ng/ml ± 35.40 vs infarcts 49.75 ng/ml ± 34.54, P > 0.005, 3 days no infarcts 72.10 ng/ml ± 70.95 vs infarcts 62.28 ± 33.84, P > 0.005, 1 week no infarcts 148.48 ng/ml ± 142.73 vs infarcts 91.5 ng/ml ± 1.20, P > 0.005). CONCLUSION: Thirty eight percent in a well-studied series of patients with SAH have DWI-MRI infarcts; the infarcts were associated to SAH severity, SAH outcome and symptomatic vasospasm. Metalloproteinase-9 was higher in SAH patients than in controls, but it could not discriminate the infarct patients.

Assessment of platelet function in acute ischemic stroke patients previously treated with aspirin.

BACKGROUND: Platelet inhibition measured by platelet function tests could be critical to understand the reasons for early recurrence and to guide therapeutic recommendations. We assess the platelet function during the acute phase of ischemic stroke in patients pretreated with aspirin who continue their treatment with aspirin only, are started on clopidogrel only, or add clopidogrel to aspirin. METHODS: Sixty-four patients were taking aspirin before the stroke. Depending on the administered antiplatelet, 3 groups were defined: ASA: patients who continued on aspirin orally or intravenous acetylsalicylate of lysine, n = 30; CLO: patients who discontinued aspirin and were started on clopidogrel, n = 16; and ASA + CLO: patients who were prescribed both aspirin and clopidogrel, n = 10. Collagen-induced thromboxane A2 (TXA2) synthesis, ADP (adenosine diphosphate)-induced aggregation, and occlusion time (PF-100) were measured. RESULTS: CLO group only had a marked elevation of TXA2 (17.44 ± 15.62 ng/mL, P = .000) and a shortening of the platelet function analyzer (PFA)-100 closure time (157.13 ± 88 seconds, P = .047) compared with the other 2 groups (ASA: TXA2, .62 ± 1.59 ng/mL; ASA + CLO: TXA2 1.79 ± 4.59 ng/mL). They achieved a small (13%) but significant reduction of ADP-induced aggregation (87.00 ± 23.06 mm, P = .008) compared with the ASA group (102.82 ± 22.38 seconds). CONCLUSIONS: Stopping aspirin intake within the first 72 hours of the acute stroke drastically increases TXA2 synthesis. During the same time window, the freshly prescribed clopidogrel manages to reduce the ADP-induced aggregation only slightly (13%). This study offers analytic proof that the common practice of replacing aspirin with clopidogrel does not leave stroke patients fully protected during the first days after an ischemic stroke. Possible solutions could be to preserve aspirin during a few days or to use loading doses of clopidogrel at hospital admission.

De la teoría a la práctica: la RM spin labeling / From theory to practice: spin labeling MRI

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TXA2 synthesis and COX1-independent platelet reactivity in aspirin-treated patients soon after acute cerebral stroke or transient ischaemic attack.

INTRODUCTION: The pharmacological target of aspirin is the inhibition of cyclooxygenase-1 (COX1) and thromboxane-A2 (TX) synthesis. Very few data are available on TX assessment in patients with stroke. We studied platelet TX synthesis, COX1-independent platelet reactivity, the influence of platelet-erythrocyte interactions and the potential association between platelet responses and the severity of stroke, evaluated with a clinical score (NIHSS). MATERIAL AND METHODS: We examined 157 aspirin-treated patients with acute stroke or TIA, 128 aspirin-free and 15 aspirin-treated healthy subjects (HS). Collagen-induced TX, platelet recruitment in whole blood and platelets ± erythrocytes (haematocrit 40%) were assessed in patients on daily-aspirin within three days from onset. Arachidonic-acid-, ADP-, thrombin-receptor activating peptide TRAP-, and collagen-induced aggregation were also evaluated. RESULTS: Partial TX inhibition (<95% inhibition vs aspirin-free controls) was observed in 13% of patients. This was associated with marked increases in COX1-dependent responses (arachidonic-acid- and collagen-induced aggregation and platelet recruitment; P<0.0001) but not with differences in ADP- or TRAP-induced aggregation. Partial TX inhibition was independently associated with severe stroke (NIHSS ≥ 12) at both admission (P<0.05) and discharge (P<0.05). Among patients with fully blocked TX, those with elevated COX1-independent platelet reactivity (mean+2SD of aspirin-treated HS) were most likely to suffer severe stroke (P<0.05). Platelet-erythrocyte interactions enhanced platelet reactivity in these patients by COX1-dependent and -independent mechanisms (P<0.0001). CONCLUSIONS: TX inhibition by aspirin varied across patients. Partial TX inhibition and COX1-independent platelet hyperfunction were associated with more-severe stroke.

Diabetes does not affect outcome of symptomatic carotid stenosis treated with endovascular techniques.

BACKGROUND: The influence of diabetes on carotid revascularization techniques is controversial, with few data regarding angioplasty and stenting (CAS). Our purpose was to analyze whether its presence constitutes a risk factor for poor outcome of patients with carotid stenosis treated with CAS. METHODS: We compared 30-day and long term morbidity and mortality, as well as restenosis rates, of non diabetic and diabetic patients with symptomatic carotid stenosis treated with endovascular techniques. RESULTS: 318 consecutive patients, 116 (36.5%) of them diabetics, were followed for a median of 56 months. Cumulative 30-day stroke, ischemic cardiopathy and death rate was 4% for non diabetics and 5.2% for diabetics (non significant). Long term stroke and mortality rate was 26.4% for the first group and 34.3% for the second (non significant). The most frequent causes of death were myocardial infarction (17.5% non diabetics, 44% diabetics, p = 0.04), ischemic stroke (12.5% non diabetics, 4% diabetics, non significant) and cancer (30% non diabetics, 16% diabetics, non significant). Twelve patients (6.4%) had restenosis ≥ 50%, 5.9% non diabetic, 7.4% diabetic, also without statistical significance. CONCLUSIONS: In our series, endovascular treatment is both efficient and safe in diabetic patients with symptomatic carotid stenosis; therefore, the presence of diabetes mellitus did not increase the risks linked to CAS procedure.

Angioplastia carotídea en estenosis tras radioterapia: revisión de 12 casos / Carotid angioplasty in stenosis following radiotherapy: a review of 12 cases

Introducción. La estenosis carotídea es una complicación de la radioterapia cervical. En estos casos, la angioplastia carotídea se ha planteado como el tratamiento de revascularización electivo. Sin embargo, la indicación de tratar es discutida, debido a la alta tasa de reestenosis y a los pocos estudios de evolución a largo plazo existentes. Objetivo. Presentar una serie de pacientes con estenosis carotídeas tras radioterapia tratadas mediante angioplastia con el fin de analizar su evolución a corto y largo plazo. Pacientes y métodos. De una serie de 426 pacientes con estenosis carotídeas tratadas endovascularmente, 12 pacientes (2,8%) habían recibido radioterapia previa en el cuello. Se realizó un seguimiento clínico y mediante imagen de todos ellos. Se recogió la tasa de complicaciones durante las primeras cuatro semanas y a largo plazo, y la tasa de reestenosis en el seguimiento. Resultados. El intervalo medio entre la radioterapia y la detección de estenosis fue de 14,7 años. Diez pacientes (83,3%) fueron sintomáticos. Durante las primeras cuatro semanas tras la angioplastia no se produjo ninguna complicación. El seguimiento medio fue de 45,09 meses: un 16,7% de pacientes presentó ictus, un 8,3% sufrió un infarto agudo de miocardio y un 33,3% falleció (16,6% a causa de cáncer). Al menos seis pacientes (50%) fueron diagnosticados de reestenosis; todas ellas fueron mayores o iguales al 50% y ninguna fue sintomática. Conclusiones. La angioplastia carotídea es una técnica segura y eficaz en la estenosis tras radioterapia, con escasas complicaciones a corto plazo. La tasa de restenosis carotídea es alta. La principal causa de fallecimiento es el cáncer(AU)

Introduction. Carotid stenosis is a complication of cervical radiotherapy. In these cases carotid angioplasty has been considered as the elective revascularisation treatment. Yet, the indication to treat is under discussion due to the high rate of restenosis and the scarcity of studies conducted on the long-term development. Aims. To report on a series of patients with carotid stenosis following radiotherapy who were treated by means of angioplasty, the aim being to analyse their long- and short-term development. Patients and methods. Of a series of 426 patients with carotid stenosis treated by endovascular means, 12 of them (2.8%) had previously received radiotherapy in the neck. All of them were submitted to a clinical and imaging follow-up. Data were collected concerning the rate of complications during the first four weeks and in the long term, as well as the rate of restenosis in the follow-up. Results. The mean interval between radiotherapy and the detection of stenosis was 14.7 years. Ten patients (83.3%) were symptomatic. No complications occurred during the first four weeks following the angioplasty. The mean follow-up time was 45.09 months: 16.7% of patients presented a stroke, 8.3% suffered acute myocardial infarction and 33.3% died (16.6% due to cancer). At least six patients (50%) were diagnosed with restenosis, all equal to or greater than 50% and none of them were symptomatic. Conclusions. Carotid angioplasty is a safe, effective technique in stenosis following radiotherapy, with few short-term complications. The rate of carotid restenosis is high. The main cause of death is cancer(AU)

Embolism and impaired washout: a possible explanation of border zone strokes in hypereosinophilic syndrome.

We describe 4 patients with stroke caused by hypereosinophilic syndrome, all of whom presented with border zone infarcts, and discuss the possible underlying mechanism. Cardioembolism (endomiocardial fibrosis) would coexist with impaired washout (perfusion disturbance due to high eosinophil count and/or eosinophil-derived substances), explaining the watershed characteristics of the infarcts.

Late clinical and radiological complications of stereotactical radiosurgery of arteriovenous malformations of the brain.

INTRODUCTION: Post-radiation injury of patients with brain arteriovenous malformations (AVM) include blood-brain barrier breakdown (BBBB), edema, and necrosis. Prevalence, clinical relevance, and response to treatment are poorly known. We present a series of consecutive brain AVM treated with stereotactic radiosurgery describing the appearance of radiation injury and clinical complications. METHODS: Consecutive patients with annual clinical and radiological follow-up (median length 63 months). Edema and BBBB were classified in four groups (minimal, perilesional, moderate, or severe), and noted together with necrosis. Clinical symptoms of interest were intracranial hypertension, new neurological deficits, new seizures, and brain hemorrhages. RESULTS: One hundred two cases, median age 34 years, 52% male. Median irradiated volume 3.8 cc, dose to the margin of the nidus 18.5 Gy. Nineteen patients underwent a second radiosurgery. Only 42.2% patients remained free from radiation injury. Edema was found in 43.1%, blood-brain barrier breakdown in 20.6%, necrosis in 6.9%. Major injury (moderate or severe edema, moderate or severe BBBB, or necrosis) was found in 20 of 102 patients (19.6%). AVM diameter >3 cm and second radiosurgery were independent predictors. Time to the worst imaging was 60 months. Patients with major radiation injury had a hazard ratio for appearance of focal deficits of 7.042 (p = 0.04), of intracranial hypertension 2.857 (p = 0.025), hemorrhage into occluded nidus 9.009 (p = 0.079), appearance of new seizures not significant. CONCLUSIONS: Major radiation injury is frequent and increases the risk of neurological complications. Its late appearance implies that current follow-up protocols need to be extended in time.

The study of deep brain structures by transcranial duplex sonography and imaging resonance correlation.

Transcranial duplex sonography (TCS) currently provides us with images of deep brain structures with sufficient resolution. We chose 2 sonographic quantitative parameters: the diameter of the third ventricle and a measurement not used by TCS to date, the midbrain area. Their reliability and reproducibility were assessed using magnetic resonance imaging (MRI) as the reference. A total of 99 patients free from neurodegenerative disorders were examined using TCS, and both parameters were measured by 2 independent explorers. Measurements of third-ventricle diameter by TCS showed very good correlation (r = 0.80) and agreement (ICC = 0.89) with measurements obtained by MRI. Measurements of the midbrain area by TCS also provided acceptable values with moderate correlation (r = 0.36) and agreement (ICC = 0.53). Interexplorer correlation values were good (ICC = 0.98 and 0.79 for the third ventricle and midbrain areas, respectively). Further studies will be required to determine the potential diagnostic usefulness of these parameters.

Postradiosurgery hemorrhage rates of arteriovenous malformations of the brain: influencing factors and evolution with time.

BACKGROUND AND PURPOSE: The long-term benefit of radiosurgery of brain arteriovenous malformations (AVM), especially nonhemorrhagic cases, is controversial. We calculated hemorrhage rates pre- and posttreatment and analyzed the risk factors for bleeding based on cases followed at our site. METHODS: One hundred eight patients, age 36 ± 17 years, 56 men. The mean follow-up was 65 ± 44 months (median, 54; interquartile range, 33-94). Most AVMs were small (74.1% <3 cm in diameter); 48.1% were located in an eloquent area, 27.8% had deep drainage, and 39.8% presented with hemorrhage. RESULTS: The annual hemorrhage rate for any undiagnosed AVM was 1.2%, and 3.3% for AVMs with hemorrhagic presentation. Older patients, cortical or subcortical AVMs, and cases with multiple draining veins were less likely to present with bleeding. During the first 36 months postradiosurgery, hemorrhagic AVMs had a rebleeding rate of 2.1%, and a rate of 1.1% from 3 years onwards. Nonhemorrhagic AVMs had a hemorrhage rate of 1.4% during the first 3 years and 0.3% afterward. Arterial hypertension and nidus volume were independent predictors of bleeding after treatment. Mean nidus obliteration time was 37 ± 18 months (median, 32; interquartile range, 25-40), with hemorrhage rate of 1.3% before and 0.6% after obliteration, and 1.9% for AVMs that were not closed at the end of follow-up. CONCLUSIONS: Both hemorrhagic and nonhemorrhagic AVMs benefit from radiosurgical therapy, with gradual decrease in their bleeding rates over the years. Albeit small, the risk of hemorrhage persists during the entirety of follow-up, being higher for cases with hemorrhagic presentation and nonobliterated AVM.

Influence of COX-inhibiting analgesics on the platelet function of patients with subarachnoid hemorrhage.

BACKGROUND: Platelet function of patients with subarachnoid hemorrhage (SAH) may play an important part in both rebleeding and delayed cerebral ischemia, but little is known about aggregation pathways during the acute phase of stroke. Analgesics are used regularly in the first days after bleeding, and some can potentially inhibit the cyclooxygenase (COX) enzyme. We examined the platelet function of patients with SAH in order to describe their basal situation and determine whether the administration of intravenous nonsteroidal antiinflammatory drugs (NSAIDs) affected platelet aggregation. METHODS: Arachidonic acid (AA)-induced aggregation and the platelet function analyzer (PFA)-100 test with collagen/epinephrine cartridges were used to study a group of SAH patients that was treated with dexketoprofen and dipyrone and to compare them to patients that had received no analgesia. RESULTS: Ninety-six consecutive SAH patients prospectively enrolled in platelet studies. Twenty-seven patients were taking NSAIDs (10 on dexketoprofen and 17 on dipyrone), and there were 15 cases in the control group. AA-induced aggregation was 10% ± 3.2% for NSAIDs (mean ± standard error), specifically 17.2% ± 7% for dexketoprofen and 5.7% ± 1% for dipyrone. Aggregation in the control group was 72.4% ± 6% (P = .001). Both analgesics slowed the platelet plug formation during the PFA-100 test, with closure times of 237.2 ± 25 seconds for dexketoprofen and 198.4 ± 22 seconds for dipyrone and 138.1 ± 21 seconds in controls (P = .02). CONCLUSIONS: The administration of COX-inhibiting analgesics leads to an hypoaggregability state in the first days of SAH. Further insight into their impact on complications such as rebleeding and delayed cerebral ischemia is needed in order to optimize the headache treatment of SAH.

Long-term outcome in patients with carotid artery stenting and contralateral carotid occlusion: a single neurovascular center prospective analysis.

INTRODUCTION: The aim of this study was to analyze the clinical features and early and late outcome of patients treated with carotid artery stenting for carotid stenosis with occlusion of the contralateral vessel (CAS-CCO), and compare them to patients without occlusion (CAS-NO). METHODS: From 1999 through 2010, 426 patients with 479 procedures were prospectively recorded, 61 patients (14.3%) CAS-CCO, and 365 patients CAS-NO. Immediate CAS complications, complications within the first 30 days and long-term complications were documented through annual clinical and ultrasonological follow-up visits. Stenosis rate was recorded. RESULTS: Patients with mean age of 68.4 years, 80% men had: (1) periprocedural stroke in three cases (0.7%), (2) cumulative 30-day stroke, ischemic cardiopathy, and death in 4.2%, without differences between groups (CAS-CCO 3.3%, CAS-NO 4.4%). Mean follow-up period was 55 ± 32.78 months, median 56 months. (3) Stroke during the follow-up in 8%, without differences between CAS-CCO and CAS-NO groups (3.7% and 8.8%). (4) Myocardial infarction in 11.2% and (5) global mortality in 24.3%, without statistical differences between groups. Of the 254 cases enrolled in the restenosis analysis, 44 patients (17.3%) had restenosis of any grade during a mean follow-up period of 52 months, without statistical differences between CAS-CCO and CAS-NO groups. Only 7.5% presented restenosis ≥ 50%. Its occurrence was statistically associated with previous neck radiation. CONCLUSIONS: Periprocedural risks and long-term outcomes of patients treated with CAS and presenting a contralateral carotid occlusion does not differ from regular patients treated with CAS. Based on the low stenosis rate of our study, our results do not give credit to extra surveillance measures in patients with contralateral carotid occlusion.

[Long-term development of carotid stenosis treated by endovascular means: a prospective study in a neurovascular unit]. / Evolución a largo plazo de la estenosis carotídea tratada endovascularmente: estudio prospectivo en una unidad neurovascular.

AIMS: Even today, unlike endarterectomy, long-term development in carotid angioplasty has still not been well defined. The aim of this study is to describe both the short- and long-term development and the rate of restenosis in a consecutive series of patients with carotid stenosis who underwent endovascular treatment at the Hospital Universitario La Fe; a distinction is made between patients with and without symptoms. PATIENTS AND METHODS: From 1999 to 2010, 426 patients were submitted to a carotid angioplasty (25.5% were asymptomatic patients). Clinical follow-ups were conducted in the case of 374 patients. They had annual check-ups and every year a neurosonological study was performed. The aim was to determine what complications occurred during the first 30 days, as well as the long-term complications, to establish the rate of restenosis and to evaluate possible differences between patients with and without symptoms. RESULTS: The morbidity and mortality rate in the first month was 4.2% (4.4% in symptomatic patients and 3.8% in asymptomatic patients). The mean follow-up time was 55 months: 8% of patients presented strokes, 11% suffered from myocardial infarct and 24.3% died, with no significant differences between patients with or without symptoms. The rate of restenosis was 17.3% at five years, 7.5% equal to or above 50% and, of those, 1.1% were symptomatic. Five patients with significant restenosis were successfully treated with endovascular techniques. CONCLUSIONS: Carotid angioplasty is an effective, safe technique in the hands of an experienced professional; our findings are good, both in the short and the long term, with a low rate of restenosis. If this latter condition occurs, vascular intervention techniques are safe and efficient.

Analysis of visual perception aspects of the virtual reality experience with transcranial Doppler monitoring.

Transcranial Doppler is a tool to measure blood flow velocity (BFV) in the main arteries of the brain that has been used in previous studies to analyze brain activity during virtual reality (VR) experiences. Increments in BFV were found during the exposure to virtual environments in comparison with baseline periods. However, due to the complexity of VR experiences, there are several factors that can be having an influence in these variations, so it is necessary to separately analyze those different aspects. In this work, we summarize our results related to visual perception. A method based on spectral analysis was used to analyze the magnitude and temporal evolution of the maximum BFV signal. Results showed that, in the presence of visual stimuli, BFV quickly rises to a maximum that is achieved after a few seconds. The contribution of the visual stimuli factor to the observed BFV variations during a VR experience can be estimated from the results of the developed work.

¿Quién controla las malformaciones arteriovenosas cerebrales no quirúrgicas en España? Réplica / No disponible

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