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1.
Clin Neurol Neurosurg ; 195: 105892, 2020 May 05.
Artigo em Inglês | MEDLINE | ID: mdl-32416324

RESUMO

OBJECTIVES: A significant proportion of patients with acute minor stroke have unfavorable functional outcome due to early neurological deterioration (END). The purpose of this study was to evaluate the applicability of machine learning algorithms to predict END in patients with acute minor stroke. PATIENTS AND METHODS: We collected clinical and neuroimaging information from patients with acute minor stroke with NIHSS score of ≤ 3. Early neurological deterioration was defined as any worsening of NIHSS score within 3 days after admission. Unfavorable functional outcome was defined as a modified Rankin Scale score of ≥ 2. We also compared clinical and neuroimaging information between patients with and without END. Four machine learning algorithms, i.e., Boosted trees, Bootstrap decision forest, Deep neural network, and Logistic Regression, were selected and trained by our dataset to predict early neurological deterioration RESULTS: A total of 739 patients were included in this study. 78 patients (10.6%) experienced END. Among 78 patients with END, 61 (78.2%) had unfavorable functional outcome at 90 days after stroke onset. On multivariate analysis, the initial NIHSS score (P = 0.003), hemorrhagic transformation (P = 0.010), and stenosis (P = 0.014) or occlusion (P = 0.004) of a relevant artery were independently associated with END. Of the four machine learning algorithms, Boosted trees, Deep neural network, and Logistic Regression can be used to predict END in patients with acute minor stroke (Boosted trees: accuracy = 0.966, F1 score = 0.8 and area under the curve = 0.934, Deep neural network :0.966, 0.8, and 0. 904, and Logistic Regression : 0.966, 0.8, and 0.885). CONCLUSIONS: This study suggests that machine learning algorithms that integrate clinical and neuroimaging information can be used to predict END in patients with acute minor stroke. Further studies based on larger, multicenter datasets are needed to predict END accurately for designing treatment strategies and obtaining favorable functional outcome.

2.
Ann Neurol ; 87(2): 233-245, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31721277

RESUMO

OBJECTIVE: Otaplimastat is a neuroprotectant that inhibits matrix metalloprotease pathway, and reduces edema and intracerebral hemorrhage induced by recombinant tissue plasminogen activator (rtPA) in animal stroke models. We aimed to assess the safety and efficacy of otaplimastat in patients receiving rtPA. METHODS: This was a phase 2, 2-part, multicenter trial in stroke patients (19-80 years old) receiving rtPA. Intravenous otaplimastat was administered <30 minutes after rtPA. Stage 1 was a single-arm, open-label safety study in 11 patients. Otaplimastat 80 mg was administered twice daily for 3 days. Stage 2 was a randomized, double-blind, placebo-controlled study involving 69 patients, assigned (1:1:1) to otaplimastat 40 mg, otaplimastat 80 mg, or a placebo. The primary endpoint was the occurrence of parenchymal hematoma (PH) on day 1. Secondary endpoints included serious adverse events (SAEs), mortality, and modified Rankin scale (mRS) distribution at 90 days (clinicaltrials.gov identifier: NCT02787278). RESULTS: No safety issues were encountered in stage 1. The incidence of PH during stage 2 was comparable: 0 of 22 with the placebo, 0 of 22 with otaplimastat 40 mg, and 1 of 21 with the 80 mg dose. No differences in SAEs (13%, 17%, 14%) or death (8.3%, 4.2%, 4.8%) were observed among the 3 groups. Three adverse events (chills, muscle rigidity, hepatotoxicity) were judged to be related to otaplimastat. INTERPRETATION: Intravenous otaplimastat adjunctive therapy in patients receiving rtPA is feasible and generally safe. The functional efficacy of otaplimastat needs to be investigated with further large trials. ANN NEUROL 2020;87:233-245.

3.
N Engl J Med ; 382(1): 9, 2020 01 02.
Artigo em Inglês | MEDLINE | ID: mdl-31738483

RESUMO

BACKGROUND: The use of intensive lipid-lowering therapy by means of statin medications is recommended after transient ischemic attack (TIA) and ischemic stroke of atherosclerotic origin. The target level for low-density lipoprotein (LDL) cholesterol to reduce cardiovascular events after stroke has not been well studied. METHODS: In this parallel-group trial conducted in France and South Korea, we randomly assigned patients with ischemic stroke in the previous 3 months or a TIA within the previous 15 days to a target LDL cholesterol level of less than 70 mg per deciliter (1.8 mmol per liter) (lower-target group) or to a target range of 90 mg to 110 mg per deciliter (2.3 to 2.8 mmol per liter) (higher-target group). All the patients had evidence of cerebrovascular or coronary-artery atherosclerosis and received a statin, ezetimibe, or both. The composite primary end point of major cardiovascular events included ischemic stroke, myocardial infarction, new symptoms leading to urgent coronary or carotid revascularization, or death from cardiovascular causes. RESULTS: A total of 2860 patients were enrolled and followed for a median of 3.5 years; 1430 were assigned to each LDL cholesterol target group. The mean LDL cholesterol level at baseline was 135 mg per deciliter (3.5 mmol per liter), and the mean achieved LDL cholesterol level was 65 mg per deciliter (1.7 mmol per liter) in the lower-target group and 96 mg per deciliter (2.5 mmol per liter) in the higher-target group. The trial was stopped for administrative reasons after 277 of an anticipated 385 end-point events had occurred. The composite primary end point occurred in 121 patients (8.5%) in the lower-target group and in 156 (10.9%) in the higher-target group (adjusted hazard ratio, 0.78; 95% confidence interval, 0.61 to 0.98; P = 0.04). The incidence of intracranial hemorrhage and newly diagnosed diabetes did not differ significantly between the two groups. CONCLUSIONS: After an ischemic stroke or TIA with evidence of atherosclerosis, patients who had a target LDL cholesterol level of less than 70 mg per deciliter had a lower risk of subsequent cardiovascular events than those who had a target range of 90 mg to 110 mg per deciliter. (Funded by the French Ministry of Health and others; Treat Stroke to Target ClinicalTrials.gov number, NCT01252875.).


Assuntos
Anticolesterolemiantes/uso terapêutico , Doenças Cardiovasculares/prevenção & controle , LDL-Colesterol/sangue , Ezetimiba/uso terapêutico , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Ataque Isquêmico Transitório/tratamento farmacológico , Acidente Vascular Cerebral/tratamento farmacológico , Adulto , Idoso , Anticolesterolemiantes/efeitos adversos , Aterosclerose/complicações , Aterosclerose/tratamento farmacológico , Isquemia Encefálica/tratamento farmacológico , Doenças Cardiovasculares/mortalidade , Quimioterapia Combinada , Feminino , Humanos , Análise de Intenção de Tratamento , Ataque Isquêmico Transitório/complicações , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Acidente Vascular Cerebral/sangue
4.
Sleep Med ; 65: 84-88, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31739230

RESUMO

OBJECTIVE: Narcolepsy is characterized by excessive daytime sleepiness and cataplexy. Attention deficit hyperactivity disorder (ADHD) is characterized by hyperactivity, inattention, and impulsivity. However, despite their differences, both narcolepsy and ADHD share the symptoms of sleep disturbance and excessive daytime sleepiness. Recent studies have suggested a link between the two disorders. The objective of systematic review was to assess the prevalence of ADHD symptoms in narcolepsy. METHODS: We performed a systematic search of MEDLINE (inception to December 2018) and EMBASE (inception to December 2018) for English publications of human studies using the keywords "narcolepsy" and "ADHD". RESULTS: Five studies examining a total of 328 patients met the eligibility criteria for this study examining the prevalence of ADHD symptoms in narcolepsy. The pooled prevalence of ADHD symptoms in narcolepsy was 33.0%. Two studies using the international classification of sleep disorders, second edition (ICSD-2) observed a pooled prevalence of ADHD symptoms in narcolepsy of 25.0%, while two other studies that relied on the ICSD-3 criteria observed a pooled prevalence of ADHD symptoms in narcolepsy of 36.4%. CONCLUSIONS: The prevalence of ADHD symptoms was >30%, making it an important comorbidity of narcolepsy. Future studies should be performed to better assess the relationship between ADHD and narcolepsy.

5.
Korean J Thorac Cardiovasc Surg ; 52(6): 392-399, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31832375

RESUMO

Background: The surgical strategies for carotid endarterectomy (CEA) vary in terms of the anesthesia method, neurological monitoring, shunt usage, and closure technique, and no gold-standard procedure has been established yet. We aimed to analyze the feasibility and benefits of CEA under regional anesthesia (RA) and CEA under general anesthesia (GA). Methods: Between June 2012 and December 2017, 65 patients who had undergone CEA were enrolled, and their medical records were prospectively collected and retrospectively reviewed. A total of 35 patients underwent CEA under RA with cervical plexus block, whereas 30 patients underwent CEA under GA. In the RA group, a carotid shunt was selectively used for patients who exhibited negative results on the awake test. In contrast, such a shunt was used for all patients in the GA group. Results: There were no cases of postoperative stroke, cardiovascular events, or mortality. Nerve injuries were noted in 4 patients (3 in the RA group and 1 in the GA group), but they fully recovered prior to discharge. Operative time and clamp time were shorter in the RA group than in the GA group (119.29±27.71 min vs. 161.43±20.79 min, p<0.001; 30.57±6.80 min vs. 51.77±13.38 min, p<0.001, respectively). The hospital stay was shorter in the RA group than in the GA group (14.6±5.05 days vs. 18.97±8.92 days, p=0.022). None of the patients experienced a stroke or restenosis during the 27.23±20.3-month follow-up period. Conclusion: RA with a reliable awake test reduces shunt use and decreases the clamp and operative times of CEA, eventually resulting in a reduced length of hospital stay.

6.
Neurology ; 93(21): e1955-e1963, 2019 11 19.
Artigo em Inglês | MEDLINE | ID: mdl-31645472

RESUMO

OBJECTIVE: To evaluate the safety and efficacy of induced hypertension in patients with acute ischemic stroke. METHODS: In this multicenter randomized clinical trial, patients with acute noncardioembolic ischemic stroke within 24 hours of onset who were ineligible for revascularization therapy and those with progressive stroke during hospitalization were randomly assigned (1:1) to the control and intervention groups. In the intervention group, phenylephrine was administered intravenously to increase systolic blood pressure (SBP) up to 200 mm Hg. The primary efficacy endpoint was early neurologic improvement (reduction in NIH Stroke Scale [NIHSS] score of ≥2 points during the first 7 days). The secondary efficacy endpoint was a modified Rankin Scale score of 0 to 2 at 90 days. Safety outcomes included symptomatic intracranial hemorrhage/edema, myocardial infarction, and death. RESULTS: In the modified intention-to-treat analyses, 76 and 77 patients were included in the intervention and control groups, respectively. After adjustment for age and initial stroke severity, induced hypertension increased the occurrence of the primary (odds ratio 2.49, 95% confidence interval [CI] 1.25-4.96, p = 0.010) and secondary (odds ratio 2.97, 95% CI 1.32-6.68, p = 0.009) efficacy endpoints. Sixty-seven (88.2%) patients of the intervention group exhibited improvements in NIHSS scores of ≥2 points during induced hypertension (mean SBP 179·7 ± 19.1 mm Hg). Safety outcomes did not significantly differ between groups. CONCLUSION: Among patients with noncardioembolic stroke who were ineligible for revascularization therapy and those with progressive stroke, phenylephrine-induced hypertension was safe and resulted in early neurologic improvement and long-term functional independence. CLINICALTRIALSGOV IDENTIFIER: NCT01600235. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that for patients with acute ischemic stroke, therapeutic-induced hypertension increases the probability of early neurologic improvement.


Assuntos
Pressão Sanguínea , Encéfalo/irrigação sanguínea , Circulação Colateral , Hipertensão , Acidente Vascular Cerebral/terapia , Idoso , Idoso de 80 Anos ou mais , Encéfalo/diagnóstico por imagem , Edema Encefálico/epidemiologia , Imagem de Difusão por Ressonância Magnética , Feminino , Humanos , Hemorragias Intracranianas/epidemiologia , Masculino , Pessoa de Meia-Idade , Mortalidade , Infarto do Miocárdio/epidemiologia , Planejamento de Assistência ao Paciente , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/fisiopatologia , Resultado do Tratamento
7.
JMIR Mhealth Uhealth ; 7(6): e13381, 2019 06 18.
Artigo em Inglês | MEDLINE | ID: mdl-31215513

RESUMO

BACKGROUND: Little is known of the effect of wearable devices on metabolic impairments in clinical settings. We hypothesized that a wearable device that can monitor and provide feedback on physical activity may help resolve metabolic syndrome. OBJECTIVE: This study aimed to examine the objective effects of the use of these devices on metabolic syndrome resolution. METHODS: Patients diagnosed with metabolic syndrome were recruited. Participants were prescribed regular walking using a wearable device (Coffee WALKIE +Dv.3, GC Healthcare CI, Korea) on their wrist for 12 weeks. Participants received self-feedback on the amount of their exercise through an app on their mobile phone. The information on physical activities of the participants was uploaded automatically to a website. Thus, a trained nurse could provide individuals with feedback regarding the physical activity via telephone consultation on alternate weeks. Blood pressure (BP), body composition, fasting plasma glucose, and lipid profiles were recorded. The primary outcome was metabolic syndrome resolution. The secondary outcome was an improvement in the components of metabolic impairment. RESULTS: Of the 53 participants recruited, 20 participants with a median age of 46 (range 36-50) years completed the trial. There was no significant difference in the amount of calorie expenditure at weeks 4, 8, and 12. After 12 weeks, metabolic syndrome was resolved in 9 of 20 participants (45%), and the mean number of metabolic impairment components per person decreased from 3.4 to 2.9. Particularly, the mean systolic and diastolic BP decreased from mean 136.6 (SD 18.5) mm Hg to mean 127.4 (SD 19.5) mm Hg and from mean 84.0 (SD 8.1) mm Hg to mean 77.4 (SD 14.4) mm Hg (both P=.02), respectively. CONCLUSIONS: This study found that a 12-week intervention via feedback, based on a wearable physical activity monitor, helped metabolic syndrome patients to be more engaged in regular walking and it improved impaired metabolic components, especially in BP. However, some practical challenges regarding patients' adherence and sustained engagement were observed.


Assuntos
Exercício Físico/psicologia , Retroalimentação , Síndrome Metabólica/terapia , Dispositivos Eletrônicos Vestíveis/normas , Adulto , Feminino , Humanos , Masculino , Síndrome Metabólica/psicologia , Pessoa de Meia-Idade , Aplicativos Móveis/normas , Aplicativos Móveis/estatística & dados numéricos , Projetos Piloto , República da Coreia , Dispositivos Eletrônicos Vestíveis/estatística & dados numéricos
8.
Front Neurol ; 10: 44, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30761076

RESUMO

Background and Purpose: Patients undergoing carotid artery stenting (CAS) who show low responsiveness to clopidogrel may have a higher risk of peri-procedural embolic events. This study aimed to compare the effectiveness and safety of clopidogrel and ticlopidine plus Ginkgo biloba in clopidogrel-resistant patients undergoing CAS. Methods: In this multi-center, randomized, controlled trial, we used platelet reactivity test to select patients undergoing CAS who showed clopidogrel resistance, and compared treatments using clopidogrel and ticlopidine plus ginkgo. The primary outcome was the incidence of new ischemic lesion in the ipsilateral hemisphere of CAS. Detection of microembolic signal on transcranial Doppler was the secondary outcome. The clinical outcomes were also monitored. Results: This trial was discontinued after 42 patients were randomized after preplanned interim sample size re-estimation indicated an impractical sample size. The primary endpoint occurred in 12/22 patients (54.5%) in the clopidogrel group and 13/20 patients (65.0%) in the ticlopidine-ginkgo group (P = 0.610). No significant differences in the presence of microembolic signal (15.0 vs. 11.8%, P = 0.580), clinical outcomes (ischemic stroke or transient ischemic attack, 0.0 vs. 5.5%; acute myocardial infarction 0.0 vs. 0.0%; all-cause death, 4.5 vs. 0.0%), or incidence of adverse events were found in the two groups. In terms of resistance to clopidogrel, treatment with ticlopidine-ginkgo significantly increased the P2Y12 Reaction Units (difference, 0.0 [-0.3-3.0] vs. 21.0 [6.0-35.0], P < 0.001). Conclusions: In patients who showed clopidogrel resistance, ticlopidine-ginkgo treatment was safe and increased P2Y12 Reaction Units; however, compared to clopidogrel, it failed to improve surrogate and clinical endpoints in patients undergoing CAS. This multimodal biomarker-based clinical trial is feasible in neurointerventional research. Clinical Trial Registration: http://www.clinicaltrials.gov. Unique identifier: NCT02133989.

9.
J Stroke Cerebrovasc Dis ; 27(12): 3591-3598, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30219629

RESUMO

BACKGROUND: Using high-resolution magnetic resonance imaging (HR-MRI), we investigated the impact of basilar artery plaques that were not detected by magnetic resonance angiography (MRA) on the functional outcomes of patients with acute pontine infarction. METHODS: A total of 40 patients with acute pontine infarction and normal basilar findings on MRA prospectively underwent HR-MRI for detection of basilar artery plaques. A relevant plaque was defined as one on the dorsal side of basilar artery, the same side of the ischemic lesion, and the same axial slices of the ischemic lesion. We analyzed the relationship between the relevant basilar artery plaques and the functional outcomes at 3 months. RESULTS: The initial National Institutes of Health Stroke Scale score (3.5 versus 2.0, P = .012), and the incidences of neurological deterioration (42.9% versus 6.3%, P = .031) and unfavorable functional outcome (71.4% versus 12.5%, P = .001) were higher in patients with relevant basilar artery plaques than in those without. On multiple regression analysis, the relevant basilar artery plaque was a significant and independent predictor of unfavorable functional outcome (odds ratio, 6.662; 95% confidence interval, 1.117-39.735; P = .037). CONCLUSIONS: The presence of a relevant basilar artery plaque was closely related with unfavorable functional outcome in patients with acute pontine infarction even if the patients' MRA showed normal basilar findings.


Assuntos
Artéria Basilar/diagnóstico por imagem , Infartos do Tronco Encefálico/diagnóstico por imagem , Angiografia Cerebral , Imagem por Ressonância Magnética , Placa Aterosclerótica/diagnóstico por imagem , Ponte/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Imagem por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos
10.
Clin Neurol Neurosurg ; 174: 156-162, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30243187

RESUMO

OBJECTIVES: To investigate the predictors of hemorrhagic transformation (HT) in patients with mild atrial fibrillation-related stroke who were treated with early anticoagulation. We conducted a post-hoc subgroup analysis from Acute Cerebral Infarction Patients with Non-valvular Atrial Fibrillation (Triple AXEL) study. PATIENTS AND METHODS: The Triple AXEL study was a randomized, multicenter, open-label, blinded end-point evaluation, comparative phase 2 trial. To identify the relationship between the type of HT and risk factors. We analyzed various factors using data from the Triple AXEL study, such as sex, history of hypertension, diabetes, microbleeds, concomitant antiplatelet use, initial infarction volume, initial infarction location, and new intracranial hemorrhage on follow-up gradient recalled echo or susceptibility-weighted imaging. RESULTS: We analyzed various factors by dividing patients into a new HT group and a no HT group. No correlation was found between HT and risk factors that were significantly associated with HT, including age, sex, history of hypertension, diabetes, microbleeds, concomitant antiplatelet use, and initial infarction volume. When the initial infarction was classified into anterior circulation infarction (ACI) and posterior circulation infarction (PCI), the occurrence of new HT was significantly more associated with PCI than with ACI (57.6% vs 24.0%, P = 0.001). Multivariate logistic regression analysis was performed using HT as a response variable. Only the location of initial infarction according to the vascular territory contributed to the increased risk of HT (OR2.3, 95%CI1.33-3.91, P = 0.003). CONCLUSION: PCI is a very important independent risk factor for HT in patients with mild AF-related stroke treated with early anticoagulation.


Assuntos
Anticoagulantes/uso terapêutico , Fibrilação Atrial/diagnóstico por imagem , Hemorragia Cerebral/diagnóstico por imagem , Progressão da Doença , Acidente Vascular Cerebral/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/tratamento farmacológico , Hemorragia Cerebral/tratamento farmacológico , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Método Simples-Cego , Acidente Vascular Cerebral/tratamento farmacológico , Resultado do Tratamento
11.
JAMA Neurol ; 74(10): 1206-1215, 2017 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-28892526

RESUMO

Importance: In atrial fibrillation (AF)-related acute ischemic stroke, the optimal oral anticoagulation strategy remains unclear. Objective: To test whether rivaroxaban or warfarin sodium is safer and more effective for preventing early recurrent stroke in patients with AF-related acute ischemic stroke. Design, Setting, and Participants: A randomized, multicenter, open-label, blinded end point evaluation, comparative phase 2 trial was conducted from April 28, 2014, to December 7, 2015, at 14 academic medical centers in South Korea among patients with mild AF-related stroke within the previous 5 days who were deemed suitable for early anticoagulation. Analysis was performed on a modified intent-to-treat basis. Interventions: Participants were randomized 1:1 to receive rivaroxaban, 10 mg/d for 5 days followed by 15 or 20 mg/d, or warfarin with a target international normalized ratio of 2.0-3.0, for 4 weeks. Main Outcomes and Measures: The primary end point was the composite of new ischemic lesion or new intracranial hemorrhage seen on results of magnetic resonance imaging at 4 weeks. Primary analysis was performed in patients who received at least 1 dose of study medications and completed follow-up magnetic resonance imaging. Key secondary end points were individual components of the primary end point and hospitalization length. Results: Of 195 patients randomized, 183 individuals (76 women and 107 men; mean [SD] age, 70.4 [10.4] years) completed magnetic resonance imaging follow-up and were included in the primary end point analysis. The rivaroxaban group (n = 95) and warfarin group (n = 88) showed no differences in the primary end point (47 [49.5%] vs 48 [54.5%]; relative risk, 0.91; 95% CI, 0.69-1.20; P = .49) or its individual components (new ischemic lesion: 28 [29.5%] vs 31 of 87 [35.6%]; relative risk, 0.83; 95% CI, 0.54-1.26; P = .38; new intracranial hemorrhage: 30 [31.6%] vs 25 of 87 [28.7%]; relative risk, 1.10; 95% CI, 0.70-1.71; P = .68). Each group had 1 clinical ischemic stroke, and all new intracranial hemorrhages were asymptomatic hemorrhagic transformations. Hospitalization length was reduced with rivaroxaban compared with warfarin (median, 4.0 days [interquartile range, 2.0-6.0 days] vs 6.0 days [interquartile range, 4.0-8.0]; P < .001). Conclusions and Relevance: In mild AF-related acute ischemic stroke, rivaroxaban and warfarin had comparable safety and efficacy. Trial Registration: clinicaltrials.gov Identifier: NCT02042534.


Assuntos
Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Inibidores do Fator Xa/uso terapêutico , Rivaroxabana/uso terapêutico , Acidente Vascular Cerebral/tratamento farmacológico , Varfarina/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico por imagem , Imagem de Difusão por Ressonância Magnética , Feminino , Seguimentos , Humanos , Hemorragias Intracranianas/etiologia , Angiografia por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , República da Coreia , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/diagnóstico por imagem , Resultado do Tratamento
12.
World Neurosurg ; 102: 598-607, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28363834

RESUMO

OBJECTIVE: To date, no controlled studies on the treatment of carotid artery dissection (CAD) have been reported. The purpose of this study was to demonstrate the technical feasibility and clinical efficacy of stent-supported angioplasty (SSA) as primary treatment for acute stroke due to CAD. METHODS: A review of medical records identified 21 patients who underwent SSA as primary treatment for acute stroke related to CAD between 2008 and 2014. The inclusion criteria were recent transient ischemic attack (n = 7, 33.3%) or acute infarct (n = 14, 66.7%) due to CAD (≥70% narrowing) with hemodynamic impairment. Technical success rates, complications, and angiographic and clinical outcomes were analyzed retrospectively. RESULTS: SSA was technically successful in all patients. Of 21 patients, 8 (38.1%) showed an additional intracranial occlusion. Intracranial recanalization to a thrombolysis in cerebral infarction ≥2b flow was achieved in 50% of the cases. Procedure-related mortality was 4.8%, and morbidity was 9.5%. Five (35.7%) of 14 patients presenting with an acute infarct showed significant improvement (decrease in National Institutes of Health Stroke Scale score of ≥4 points compared with admission score) at 7 days after SSA. During the observation period (mean, 20.5 months), stroke recurrence occurred in only 1 patient (5%), resulting in an annual stroke risk of 2.9%. A favorable outcome (modified Rankin Scale score ≤2) was achieved in all 7 patients with a transient ischemic attack (100%) and in 7 of 14 patients with an acute infarct (50%) at the 90-day follow-up. CONCLUSION: Our results provide evidence that SSA is a feasible and effective strategy as primary treatment for steno-occlusive CAD patients with significant hypoperfusion or a large penumbra.


Assuntos
Aneurisma Dissecante/cirurgia , Doenças das Artérias Carótidas/cirurgia , Artéria Carótida Primitiva/cirurgia , Procedimentos Endovasculares/métodos , Stents , Adulto , Idoso , Aneurisma Dissecante/diagnóstico por imagem , Aneurisma Dissecante/fisiopatologia , Doenças das Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/fisiopatologia , Artéria Carótida Primitiva/diagnóstico por imagem , Artéria Carótida Primitiva/fisiologia , Artéria Carótida Interna/fisiopatologia , Artéria Carótida Interna/cirurgia , Angiografia Cerebral/métodos , Infarto Cerebral/diagnóstico por imagem , Infarto Cerebral/fisiopatologia , Infarto Cerebral/cirurgia , Feminino , Seguimentos , Hemodinâmica/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/cirurgia
13.
J Clin Neurosci ; 41: 66-70, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28262403

RESUMO

BACKGROUND AND PURPOSE: Patients who have acute stroke symptoms present on awakening are ineligible for standard intravenous thrombolysis due to the unclear onset time of symptoms. Some of these wake-up stroke (WUS) patients may benefit from endovascular recanalization. This study aimed to evaluate clinical predictors of outcomes from endovascular recanalization in WUS patients. METHODS: Forty-one WUS patients with internal carotid (ICA) or middle cerebral artery (MCA) occlusion treated with endovascular recanalization were reviewed. Regression analysis was performed to measure clinical predictors of outcomes from endovascular recanalization in WUS patients. RESULTS: The mean initial NIHSS score was 16.41±4.96 (5-24). The mean symptom recognition-to-door time (SRDT) was 108.85±65.80 (19-230)min. Successful recanalization (TICI 2b-3) was achieved in 29 patients (70.7%). Thirty-four patients improved on NIHSS (amount 7.59±4.84, range; 1-17) at 7days after recanalization. At 90days after recanalization, a mRS of ≤2 was achieved in 19 patients (46.3%) and a mRS of ≤3 was achieved in 24 patients (58.5%). No symptomatic intracerebral hemorrhage occurred. Multivariate regression analysis identified SRDT (P=0.019), successful recanalization (P=0.005), and hypertension (P=0.013) were factors associated with an improvement of the NIHSS score. For a good functional outcome at 90days, SRDT (P=0.036) and initial NIHSS score (P=0.016) were found to be significant predictors. CONCLUSIONS: The results of this study suggest that the SRDT is an independent predictor of both an improvement of NIHSS score and a good functional outcome in endovascular recanalization for WUS patients.


Assuntos
Hemorragia Cerebral/epidemiologia , Revascularização Cerebral/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Acidente Vascular Cerebral/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Hemorragia Cerebral/diagnóstico , Hemorragia Cerebral/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Acidente Vascular Cerebral/cirurgia
14.
Ann Vasc Dis ; 9(4): 295-299, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-28018501

RESUMO

Background: Carotid endarterectomy (CEA) is the standard treatment modality for the prevention of stroke in patients with carotid stenosis. This study reports our experiences during CEA with routine awake tests under regional anesthesia (RA) combined with light sedation by dexmedetomidine infusion. Materials and Methods: We retrospectively reviewed 23 patients who had undergone CEA between April 2013 and June 2015. All patients underwent the awake test during CEA with cervical plexus block and light sedation by continuous dexmedetomidine infusion. Results: Mean operation and clamp times were 108.5 ± 20.1 min and 30.1 ± 6.9 min, respectively. Selective shunt placement was performed in three patients (13.0%). There were no cases of perioperative stroke, myocardial infarction, or death. There were no occurrences of residual stenosis, thrombosis, or dissection. One patient had a hypoglossal nerve injury but fully recovered before discharge. Mean (± standard deviation) hospital stay was 7.5 ± 2.6 days. There were no incidences of death, stroke, or restenosis during a mean follow-up period of 9.2 ± 8.8 months. Conclusions: RA with dexmedetomidine infusion appears to be a safe and feasible option. A lower shunt placement rate and favorable patient outcomes were observed following the awake test during CEA.

16.
Interv Neuroradiol ; 21(4): 511-9, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26063697

RESUMO

The purpose of this study is to assess the technical feasibility and clinical efficacy of percutaneous transluminal angioplasty and stenting (PTAS) for symptomatic stenosis of the intracranial extradural (petrous and cavernous) internal carotid artery (ICA).Review of medical records identified 26 consecutive patients who underwent PTAS using a balloon-expandable coronary stent (n = 15, 57.7%) or a Wingspan self-expandable stent (n = 11, 42.3%) for treatment of severe stenosis (>70%) involving the intracranial extradural ICA. The inclusion criteria were transient ischemic attack with an ABCD(2) score of ≥3 (n = 12, 46.2%) or minor stroke with an NIHSS score of ≤4 (n = 14, 53.8%). Technical success rates, complications, and angiographic and clinical outcomes were analyzed retrospectively.PTAS was technically successful in all patients. The mean stenosis ratio decreased from 77.1% to 10.0% immediately after PTAS. The overall incidence of procedural complications was 23.1%, and the postoperative permanent morbidity/mortality rate was 7.7%. A total of 22 patients were tracked over an average period of 29.9 months. During the observation period, 20 patients (90.9%) had no further cerebrovascular events and stroke recurrence occurred in two patients (9.1%), resulting in an annual stroke risk of 3.7%. Two cases (11.1%) of significant in-stent restenosis (>50%) were found on follow-up angiography (n = 18).PTAS for severe stenosis (>70%) involving the intracranial extradural ICA showed a good technical feasibility and favorable clinical outcome in patients with transient ischemic attack or minor stroke.


Assuntos
Angioplastia/métodos , Artéria Carótida Interna/cirurgia , Estenose das Carótidas/complicações , Estenose das Carótidas/cirurgia , Ataque Isquêmico Transitório/etiologia , Procedimentos Neurocirúrgicos/métodos , Stents , Acidente Vascular Cerebral/etiologia , Adulto , Idoso , Artéria Carótida Interna/diagnóstico por imagem , Estenose das Carótidas/diagnóstico por imagem , Angiografia Cerebral , Estudos de Viabilidade , Feminino , Seguimentos , Oclusão de Enxerto Vascular/epidemiologia , Humanos , Ataque Isquêmico Transitório/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico por imagem , Resultado do Tratamento
17.
Clin Neurol Neurosurg ; 131: 72-6, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25710708

RESUMO

OBJECTIVE: Collateral flow is important for ischemic brain tissue after an acute occlusion of the cerebral artery. The purpose of this study was to evaluate baseline collateral flow, on CT angiography (CTA), as a predictor of functional outcome in patients who had endovascular recanalization, after acute pure first segment (M1) occlusion of the middle cerebral artery (MCA). METHODS: Thirty patients with acute pure M1 occlusion treated by endovascular recanalization, who were ineligible for intravenous thrombolysis or resistant to intravenous thrombolysis, were reviewed. The relationship between baseline collateral flow, on CTA, and functional outcome, was analyzed. In addition, other factors affecting clinical outcome were assessed. RESULTS: The mean NIHSS score on admission was 16.87±4.86 (7-24). The mean time interval between onset of stroke symptoms and recanalization was 324.37±68.38 (210-463) min. Successful recanalization (TICI 2b-3) was achieved in 18 patients (60%). Twenty-seven of 30 patients improved their NIHSS score (mean 8.4); NIHSS score 8.9±5.4 (median 10, range 0-16) at seven days. Two patients had aggravated symptoms and one patient had no change on the NIHSS score. At 90 days after recanalization, a modified Rankin Scale (mRS) of ≤3 was achieved in 15 patients (50%) and a mRS of ≤2 was achieved in nine patients (30%). Symptomatic intra-cerebral hemorrhage occurred in two patients (6.7%). Multivariate regression analysis showed an initial NIHSS score (p=0.004), grade of baseline collateral flow on CTA (p=0.025), presence of diabetes mellitus (p=0.037), and TICI scale (p=0.049) were factors associated with an improved NIHSS. For the mRS at 90 days, only the grade of the baseline collateral flow on CTA was associated with a good functional outcome (p=0.013). CONCLUSIONS: The results of this study suggest that the grade of baseline collateral flow, on CTA, is an independent predictor of functional outcome for endovascular recanalization of acute pure M1 occlusion of the middle cerebral artery.


Assuntos
Circulação Cerebrovascular/fisiologia , Procedimentos Endovasculares/métodos , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Infarto da Artéria Cerebral Média/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Angiografia Cerebral , Hemorragia Cerebral , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
18.
Ann Neurol ; 77(4): 726-33, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25627980

RESUMO

We prospectively recruited 10 patients who presented with urinary retention as a neurological deficit that was attributable to lateral medullary infarction. Of these, 9 patients underwent a urodynamic study, which demonstrated detrusor underactivity of the bladder in 7 patients. Urinary retention developed mainly when the lesions involved the lateral tegmentum of the middle or caudal medulla. We concluded that interruption of the descending pathway from the pontine micturition center to the sacral spinal cord in the lateral medulla was responsible for the development of urinary retention.


Assuntos
Isquemia Encefálica/diagnóstico , Bulbo/patologia , Tratos Piramidais/anatomia & histologia , Acidente Vascular Cerebral/diagnóstico , Retenção Urinária/diagnóstico , Idoso , Isquemia Encefálica/complicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Acidente Vascular Cerebral/complicações , Retenção Urinária/etiologia
19.
J Korean Neurosurg Soc ; 55(6): 313-20, 2014 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25237426

RESUMO

OBJECTIVE: The purpose of this study is to demonstrate the technical feasibility and clinical efficacy of emergent carotid angioplasty and stenting (CAS) for acute stroke due to athero-thrombotic occlusion of the cervical internal carotid artery (ICA). METHODS: Review of medical records identified 17 patients who underwent emergent CAS for treatment of athero-thrombotic occlusion of the cervical ICA with acute stroke between 2009 and 2013. Eleven patients (64.7%) presented with concomitant intracranial artery occlusion, which was treated primarily by mechanical thrombectomy after CAS. RESULTS: Successful revascularization of the cervical ICA with emergent CAS was achieved in all patients. After CAS, intracranial recanalization with Thrombolysis in Cerebral Infarction ≥2b flow was achieved in four of the 11 patients (36.4%). The overall recanalization rate (cervical ICA and intracranial artery) was 10 of 17 patients (58.8%). Symptomatic intracranial hemorrhage occurred in two patients (11.8%), resulting in death. Ten patients (58.8%) showed improvement (decrease in NIHSS score of ≥4 points) at seven days after recanalization. Nine patients (52.9%) showed a favorable outcome (mRS ≤2) at the last follow-up. A favorable outcome (mRS ≤2) was obtained in four of the six patients with isolated cervical ICA occlusion (4/6, 66.7%) and five of 11 patients with intracranial tandem occlusion (5/11, 45.5%). CONCLUSION: Emergent CAS for acute stroke due to athero-thrombotic occusion of the cervical ICA showed a good technical feasibility and favorable clinical outcome.

20.
J Stroke Cerebrovasc Dis ; 23(7): 1915-20, 2014 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-24796663

RESUMO

BACKGROUND: Recent studies have shown that thyroid autoantibodies contribute to the development of cerebrovascular diseases, including atherosclerosis, moyamoya disease, and even arterial dissection, induced by immune-mediated endothelial dysfunction on the cerebral vasculature. The aim of this study was to investigate the impact of thyroid autoantibodies on functional outcome in patients with acute ischemic stroke. METHODS: We reviewed the patients with acute ischemic stroke who consecutively underwent thyroid autoantibody tests. We divided the patients into positive thyroid autoantibody (PAB) and negative thyroid autoantibody (NAB) groups. Demographic profiles, risk factors, stroke subtypes, laboratory results, and functional outcomes were compared between the 2 groups. We performed the multivariate analysis to determine whether thyroid autoantibodies were independently associated with functional outcome. RESULTS: Of the 763 patients, 121 (15.9%) were of the PAB group. Compared with the NAB group, higher baseline National Institutes of Health Stroke Scale score (P = .001) and prevalence of large-artery atherosclerosis (P = .014) were found in the PAB group. The PAB group had significantly higher proportion of unfavorable outcome at 3 months (modified Rankin Scale score ≥ 3) than the NAB group (P = .002). On multiple regression analysis, lower tri-iodothyronine level (odds ratio [OR] .985, 95% confidence interval [CI] .976-.995, P = .002) and PABs (OR 1.661, 95% CI 1.013-2.724, P = .044) were significant and independent predictors of unfavorable outcome. CONCLUSIONS: This study showed that elevated thyroid autoantibodies were independently associated with unfavorable outcome in patients with acute ischemic stroke. We speculate that immune-mediated vascular damage may contribute to the increased risk of unfavorable outcome by providing insufficient cerebral blood flow to the ischemic area.


Assuntos
Autoanticorpos/análise , Isquemia Encefálica/imunologia , Isquemia Encefálica/terapia , Acidente Vascular Cerebral/imunologia , Acidente Vascular Cerebral/terapia , Glândula Tireoide/imunologia , Idoso , Autoanticorpos/imunologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Terapia Trombolítica , Testes de Função Tireóidea , Hormônios Tireóideos/sangue , Resultado do Tratamento
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