Accidente cerebrovascular de la arteria basilar: cannabis como factor de riesgo en jóvenes / Cerebrovascular accident of basilar artery: Cannabis as a risk factor in young people / Acidente Vascular Cerebral (AVC) da artéria basilar: cannabis como fator de risco em jovens

Introducción. La arteria basilar se forma de las arterias vertebrales, cursa sobre el puente y se bifurca originando las arterias cerebrales posteriores. Irriga parte del tronco encefálico, cerebelo, tálamo y los lóbulos occipitales y temporales cerebrales. Su obstrucción es rara (1% de los accidentes isquémicos), puede ocurrir en cualquier parte de su trayecto, con cuadro clínico diverso. En jóvenes se añaden otros factores de riesgo distintos a los cardiovasculares, se incluye el consumo de sustancias psicoactivas. El objetivo de este artículo es presentar el caso de un adulto joven, su evolución posterior a la intervención endovascular y la asociación, pasada por alto, al consumo de cannabinoides. Caso clínico. Individuo de 23 años con 14 horas de parálisis facial periférica derecha, diplopía, disartria, hemiparesia e hiperreflexia izquierda, disfagia, náuseas y emesis. Tomografía Axial Computarizada de cráneo simple sin alteraciones. Posteriormente, al realizarse resonancia magnética nuclear, se evidencia isquemia pontomesencefálica y focos isquémicos agudos lacunares en lóbulos cerebelosos. Se consideró comprometido el territorio de la arteria basilar, por lo que se realizó angiotomografía que evidenció una obstrucción crítica de dicho vaso a nivel del tercio distal. Se realizó trombectomía con stent-retriever con recanalización total de la arteria basilar con flujo en toda su extensión. Al egreso fue clasificado como TOAST idiopático. Conclusiones. Las escalas etiológicas para stroke creadas para adultos mayores sobreestiman la etiología idiopática en pacientes jóvenes, lo cual puede ocasionar que el consumo de cannabis sea pasado por alto como causante pese a la asociación reportada por la literatura.

Introduction. The basilar artery is formed from the vertebral arteries, runs over the pons and bifurcates, originating the posterior cerebral arteries. It irrigates part of the brainstem, cerebellum, thalamus, and the occipital and temporal lobes of the brain. Its obstruction is rare (1% of ischemic accidents), it can occur in any part of its path, with a diverse clinical condition. In young people, other risk factors other than cardiovascular ones are added; psychoactive substance use is included. The objective of this article is to present the case of a young adult, his evolution after endovascular intervention and the association, overlooked, to the consumption of cannabinoids. Clinical case. 23-year-old man with 14 hours of right peripheral facial paralysis, diplopia, dysarthria, left hyperreflexia and hemiparesis, dysphagia, nausea and emesis. Simple skull Computerized Axial Tomography without alterations. Subsequently, when a nuclear magnetic resonance was performed, pontomesencephalic ischemia and acute lacunar ischemic foci in the cerebellar lobes were evidenced. The basilar artery territory was considered compromised, so a CT angiography was performed, which revealed a critical obstruction of said artery at the level of the distal third. A stent-retriever thrombectomy was performed with total recanalization of the basilar artery with flow in its entirety. Upon discharge, he was classified as "idiopathic" according to the TOAST classification. Conclusions. The etiological scales for stroke created for older adults overestimate idiopathic etiology in young patients, which may cause cannabis use to be overlooked as a cause despite the association reported in the literature.

Introdução. A artéria basilar é formada pelas artérias vertebrais, passa pela ponte e se bifurca, originando as artérias cerebrais posteriores. Irriga parte do tronco cerebral, cerebelo, tálamo e os lobos occipital e temporal do cérebro. Sua obstrução é rara (1% dos acidentes isquêmicos), podendo ocorrer em qualquer parte de seu trajeto, com quadro clínico diverso. Nos jovens, são adicionados outros fatores de risco além dos cardiovasculares, incluindo o consumo de substâncias psicoativas. O objetivo deste artigo é apresentar o caso de um adulto jovem, sua evolução após a intervenção endovascular e a associação, despercebida, ao consumo de canabinoides. Caso clínico. Indivíduo de 23 anos com 14 horas de paralisia facial periférica direita, diplopia, disartria, hemiparesia e hiperreflexia esquerda, disfagia, náuseas e vômitos. Tomografia axial computadorizada de crânio simples sem alterações. Posteriormente, quando foi realizada a ressonância magnética nuclear, foram evidenciados isquemia pontomesencefálica e focos agudos de isquemia lacunar nos lobos cerebelares. O território da artéria basilar foi considerado comprometido, por isso foi realizada uma angiotomografia, que revelou uma obstrução crítica do referido vaso no terço distal. Foi realizada trombectomia stent-retriever com recanalização total da artéria basilar com fluxo em sua totalidade. No momento da alta, foi classificado como TOAST idiopática. Conclusões.As escalas etiológicas para AVC criadas para idosos superestimam a etiologia idiopática em pacientes jovens, o que pode fazer com que o uso de cannabis seja negligenciado como causa, apesar da associação relatada na literatura.

Dual Mechanical Thrombectomy for Recanalization of a Resistant Acute Posterior Circulation Stroke

A 71-year-old man with acute basilar artery occlusion was referred for endovascular treatment 6 hours after the onset of stroke with a Glasgow Coma Score of 3 and National Institutes of Health Stroke Scale of 27. A cerebral arteriogram revealed occlusion of the left vertebral artery proximally and thromboembolic occlusion of the basilar tip. Direct aspiration and mechanical thrombectomy with various stent retrievers failed to reconstitute arterial flow in the basilar artery. Thrombolysis in cerebral infarction 2b recanalization was achieved only after placement of double Catch Mini stent retrievers through 2 microcatheters, on both side branches of the basilar bifurcation in a kissing fashion and retrieving them simultaneously. It was possible to perform this maneuver through a single distal access catheter without any complications. On follow-up the patient awakened and was able to follow commands on his right side. To our knowledge, dual mechanical thrombectomy with stent retrievers has not been reported in the posterior circulation previously. This technique may be useful in retrieving thrombi located at major intracranial bifurcations of the posterior circulation which do not recanalize with standard mechanical thrombectomy procedures. Although bilateral access to the basilar artery through both vertebral arteries is an advantage in posterior circulation for this technique, dual mechanical thrombectomy can also be performed through a unilateral access.

Primary stent retrieval for acute intracranial large artery occlusion due to atherosclerotic disease / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: The goal of stent retriever-based thrombectomy is removal of embolic clots in patients with intracranial large artery occlusion. However, outcomes of stent retrieval may differ between acute arterial occlusions due to intracranial atherosclerotic disease (IAD) and those due to embolism. This case series describes the outcomes of stent retriever-based thrombectomy and rescue treatments in 9 patients with IAD-related occlusion. METHODS: Among patients who underwent endovascular treatment for acute intracranial large artery occlusion, those in whom stent retrieval was attempted as first-line treatment were included in this review. IAD was defined as significant fixed focal stenosis at the occlusion site, which was evident on final angiographic assessment or observed during endovascular treatment. RESULTS: Median number of stent retriever passes was 2 (range, 1-3), and temporary bypass was seen in all patients. Immediate partial recanalization (arterial occlusive lesion grade 2-3) was observed in 7 patients. Immediate modified thrombolysis in cerebral infarction grade 2b-3 was seen in 6 patients, but the lesions often required rescue treatment due to reocclusion or flow insufficiency. In terms of rescue treatments, angioplasty and intra-arterial tirofiban infusion seemed to be effective. CONCLUSIONS: Our findings suggest that stent retrieval can effectively remove thrombi from stenotic lesions and achieve partial recanalization despite the tendency toward reocclusion in most patients with IAD-related occlusion. Further research into the use of rescue treatments, such as tirofiban infusion and angioplasty, is warranted.

Primary stent retrieval for acute intracranial large artery occlusion due to atherosclerotic disease / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: The goal of stent retriever-based thrombectomy is removal of embolic clots in patients with intracranial large artery occlusion. However, outcomes of stent retrieval may differ between acute arterial occlusions due to intracranial atherosclerotic disease (IAD) and those due to embolism. This case series describes the outcomes of stent retriever-based thrombectomy and rescue treatments in 9 patients with IAD-related occlusion. METHODS: Among patients who underwent endovascular treatment for acute intracranial large artery occlusion, those in whom stent retrieval was attempted as first-line treatment were included in this review. IAD was defined as significant fixed focal stenosis at the occlusion site, which was evident on final angiographic assessment or observed during endovascular treatment. RESULTS: Median number of stent retriever passes was 2 (range, 1-3), and temporary bypass was seen in all patients. Immediate partial recanalization (arterial occlusive lesion grade 2-3) was observed in 7 patients. Immediate modified thrombolysis in cerebral infarction grade 2b-3 was seen in 6 patients, but the lesions often required rescue treatment due to reocclusion or flow insufficiency. In terms of rescue treatments, angioplasty and intra-arterial tirofiban infusion seemed to be effective. CONCLUSIONS: Our findings suggest that stent retrieval can effectively remove thrombi from stenotic lesions and achieve partial recanalization despite the tendency toward reocclusion in most patients with IAD-related occlusion. Further research into the use of rescue treatments, such as tirofiban infusion and angioplasty, is warranted.

Complete spontaneous thrombosis of a non-giant middle cerebral artery aneurysm: report of two cases / Trombose espontânea de aneurisma da artéria cerebral média: relato de dois casos

Spontaneous intra-aneurysmal thrombosis occurs in approximately 50% of giant intracranial aneurysms. The incidence of this process is associated to location, size, and origin, and the natural history of spontaneous thrombosis occurrence in non-giant aneurysms is rare and still unclear. We describe two non-giant middle cerebral artery (MCA) aneurysms that spontaneously thrombosed and comment the aspects of the literature.

Trombose intra-aneurismática espontânea ocorre em aproximadamente 50% dos aneurismas intracranianos gigantes. A incidência é associada a localização, tamanho e origem, e a história natural da ocorrência de trombose espontânea em aneurismas não gigantes é rara e ainda indefinida. Descrevemos dois aneurismas de artéria cerebral média com trombose espontânea e comentamos os aspectos da literatura.

Infarto cerebeloso en el puerperio inmediato / Headache after a dural puncture in obstetric patient

La enfermedad cerebrovascular durante la gestación es rara. El presente trabajo tiene como objetivo describir las características clínicas de una paciente con embolismos de la arteria humeral derecha y tallo encefálico en el periodo expulsivo de un parto eutócico sin foco embolígeno causante de dicho accidente cerebrovascular. Se presenta el caso de una parturienta de 29 años con 40,2 semanas de edad gestacional que durante el periodo expulsivo de un parto eutócico comenzó a presentar dolor intenso en el miembro superior derecho con cambios de coloración y temperatura e impotencia funcional, imposibilidad para la apertura palpebral bilateral, vómitos sin náuseas, disartria y dificultad en los movimientos oculares...

The cerebrovascular disease during pregnancy is uncommon. The objective of present paper is to describe the clinical features of a patient with embolisms of the right humeral artery and of the brainstem at expulsion period of a spontaneous labor without emboligen focus causing this cerebrovascular accident...

Infarto cerebeloso en el puerperio inmediato / Cerebella infarction in the immediate puerperium

La enfermedad cerebrovascular durante la gestación es rara. El presente trabajo tiene como objetivo describir las características clínicas de una paciente con embolismos de la arteria humeral derecha y tallo encefálico en el periodo expulsivo de un parto eutócico sin foco embolígeno causante de dicho accidente cerebrovascular. Se presenta el caso de una parturienta de 29 años con 40,2 semanas de edad gestacional que durante el periodo expulsivo de un parto eutócico comenzó a presentar dolor intenso en el miembro superior derecho con cambios de coloración y temperatura e impotencia funcional, imposibilidad para la apertura palpebral bilateral, vómitos sin náuseas, disartria y dificultad en los movimientos oculares...

The cerebrovascular disease during pregnancy is uncommon. The objective of present paper is to describe the clinical features of a patient with embolisms of the right humeral artery and of the brainstem at expulsion period of a spontaneous labor without emboligen focus causing this cerebrovascular accident...

Trombose intracardíaca na síndrome do anticorpo antifosfolipídio como fonte de acidente vascular cerebral / Intracardiac thrombosis in antiphospholipid antibody syndrome as a source of stroke

O acometimento cardíaco, nos portadores de síndrome do anticorpo antifosfoslipídio (SAAF) é relativamente comum, e pode ser detectado pela ecocardiografia transtorácica em mais de um terço dos pacientes. Frequentemente, manisfesta-se como espessamento valvular e pequenas vegetações (endocardite trombótica não bacteriana ou de Libman-Sacks), sendo rara a ocorrência de trombose intracardíca. Relata-se o caso de paciente feminima, 48 anos, com diagnóstico prévio de SAAF primária, que foi admitida na emergência de um hospital terciário com hemiparesia esquerda e redução do nível de consciência, evoluíndo rapidamente com AVC isquêmico extenso e instabilidade hemodinâmica, sendo identificada, ao ecocardiograma transtorácico, volumosa massa móvel e pedunculada aderida à mitral (>4cm), sugerindo provável etiologia cardioembólica. A paciente apresentou evolução clínica surpreendentemente favorável, com resolução completa da massa, após tratamento empírico com heparinização plena e imunoglobulina intravenosa. Recebeu alta do hospital 30 dias após a admissão, com sequelas neurológicas mínimas, sendo mantido o tratamento com cumarínico oral e AAS em dose profilática.

Trombosis de la arteria cerebral media en un neonato afectado de déficit de proteína C / Perinatal stroke associated with protein-C deficiency

Los accidentes cerebrovasculares (ACV) son una causa frecuente de mortalidad y morbilidad neurológica crónica en niños. El ACV perinatal se define como aquel que ocurre entre la semana 28 de gestación y los 28 días de vida. Se suele manifestar en forma de convulsiones en las primeras semanas de vida, aunque puede permanecer asintomático hasta meses después del parto, cuando aparecen alteraciones en la lateralidad de la función motora fina, fallo al alcanzar los hitos del desarrollo o convulsiones. Gracias a la mejora de los métodos diagnósticos de imagen, esta patología se ha incluido como diagnóstico diferencial en los recién nacidos con sintomatología neurológica. Los obstetras se encargan del seguimiento de los embarazos de alto riesgo trombótico, pero rara vez tienen en cuenta el efecto de este riesgo en el feto o en el recién nacido. Se presenta un caso de ACV perinatal asociado a déficit de proteína C (AU)

Stroke is an important cause of mortality and chronic neurological morbidity in children. Perinatal stroke has been defined as a cerebrovascular event occurring between 28 weeks of fetal life and the 28th postnatal day. The most common manifestation of stroke is neonatal seizures but this entity may also be asymptomatic until months after birth when asymmetry of reach and grasp, failure to reach developmental milestones, or postnatal seizures can develop. Improvements in neuroimaging and its availability have increased the diagnosis and awareness of perinatal stroke in newborns and infants with neurological symptoms. Obstetricians are responsible for monitoring pregnancies at high thromboembolic risk, but rarely consider the effect this has on the fetus or newborn. We present the case of a newborn with perinatal stroke associated with protein-C deficiency (AU)

Estudios de hipercoagulabilidad en oftalmología. ¿Qué pedir y cuándo? / Hypercoagulable workup in ophthalmology. When and What?

La mayoría de los trastornos oftalmológicos secundariosa hipercoagulabilidad se deben a la confluenciade factores congénitos y adquiridos. Dada la multitudde test diagnósticos existentes se hace precisouna sistematización de la solicitud de los mismos.La mayoría de los trastornos congénitos de la coagulaciónproducen trombosis venosas y son deherencia autosómica dominante. Los más frecuentesson por este orden la resistencia a la proteína Cactivada (Factor V Leiden), la mutación del gen dela protrombina (G20210A), déficit de proteína Cproteína S y de antitrombina III. La anemia de célulasfalciformes puede acompañarse de fenómenosoclusivos arteriales y venosos.Respecto a las trombosis arteriales, los marcadoresimplicados más frecuentemente son los niveles dehomocisteína en ayunas y los del síndrome de anticuerposantifosfolípidos, aunque ambos producenoclusiones venosas fundamentalmente.Diversos factores adquiridos pueden producir estadoshipercoagulables. Dentro de las entidades másfrecuentes destacamos la hiperhomocisteinemia y elsíndrome de anticuerpos antifosfolípidos, sin olvidarmúltiples circunstancias como patología hepática,ingesta de alcohol, tabaco, anticonceptivos orales,inmovilización, cirugía y enfermedades mieloproliferativas que pueden potenciar su desarrollo.En la oclusión de vena central de la retina sólo seindica descartar hiperhomocisteinemia y síndromede anticuerpos antifosfolípidos en pacientes jóvenessin factor de riesgo conocido.En la embolia de la arteria central de la retina, sólose recomienda estudio en menores de 50 años sinorigen de émbolo detectable (jóvenes con alto riesgo).En este caso se investigará: proteína C, S, antitrombinaIII, homocisteína, electroforesis de hemoglobinay síndrome antifosfolípido.En la neuropatía óptica isquémica no arterítica nose precisan estudios de hipercoagulabilidad(AU)

Ante una amaurosis fugax sin fuente embolígenaconocida se recomienda la búsqueda de alteracionesrelacionadas con oclusiones arteriales, fundamentalmentedéficit de antitrombina III, hiperhomocisteinemia,síndrome antifosfolípido y la enfermedadde células falciformes(AU)

ABSTRACTMost ophthalmologic disorders secondary to hypercoagulabestate are due to the confluence of congenitaland adquired factors. A systematic workup ismandatory.Most of congentital coagulation disorders causevenous trombosis and are inherited autosomaldominantly. In order of frequency these are factor VLeiden mutation (activated protein C resistance),G20210A mutation of the prothrombin gen and proteinC, protein S, and antithrombin III deficiencies.Sickle cell anemia can determine arerial and venousthrombosis.In relation with arterial occlusion, the markers mostfrequently involved are homcysteine fasting levelsand the markers of antiphospholipid antibodysyndrome. Both of them can also determine venousthrombosis.Several acquired factors can lead to hypoercoagulablestate, especially hyperhomocysteinemia, antiphospholipidantibody syndrome, hepatic disease,alcohol and tobacco intake, oral contraceptives,immobilization, surgeries and malignancies.In central venous occlusion is only necessary to ruleout hyperhomocysteinemia and antiphospholipidantibody syndrome in young patients without known risk factors. In central artery occlusion, hypercoagulable workupis only recommended for patients less than 50years-old with unknown emboli source. In thiscases protein C, protein S, and antithrombin IIIdeficiencies, homocystein, sickle cell diseae andantiphospholipid antibody syndrome will ruled out.In non arteritic ischemic optic neuropathy hypercoagulablework up is not necessary.In amaurosis fugax without known emboli source, it is recommended to rule out etiologies of arterial occlusion, especially antithrombin III deficiencies, homocystein, sickle cell diseae and antiphospholipid antibody syndrome(AU)

Long-term Prognosis of Patients With Acute Intracranial Large Artery Occlusion and its Determining Factors

BACKGROUND: Acute intracranial large-artery occlusions (AILAOs) are detected frequently and cause severe neurological disabilities. Most studies in this field do not focus on the natural history of AILAOs, but on the individual prognosis for each intervention. The aim of this study was to elucidate the clinical profiles and outcomes of AILAOs. METHODS: A consecutive series of patients hospitalized between January 2004 and October 2007 due to AILAO within 24 hours from onset were recruited. Based on a prospective stroke registry, their clinical profiles were collected. AILAO was defined as an intracranial internal carotid artery (ICA), middle cerebral artery (MCA), or basilar artery (BA) occlusion that could be confirmed by angiography, with relevant lesions on diffusion-weighted imaging (DWI). The modified Rankin Scale (MRS) score at 3 months and the recanalization rate within 14 days were recorded as outcomes. RESULTS: Among 1,047 patients with acute ischemic stroke who were examined within 24 hours of onset, 189 [18.1%; 101 men, 88 women; age 68.6+/-13.0 years (mean+/-SD); median National Institutes of Health Stroke Scale (NIHSS) score=11]. Occlusion sites were MCA M1, MCA M2, distal ICA, and BA in 99 (52.4%), 50 (26.5%), 20 (10.6%), and 20 (10.6%) of cases,respectively. Embolic sources were found in 103 (54.5%) cases. MRS scores were available for 184 (97.4%) of the patients, of which 78 had a favorable outcome (MRS: 0.2). Follow-up angiography was performed in 122 (64.6%) cases, with recanalization observed in 88 (72.1%) of these. Thrombolysis, occlusion site, presence of an embolic source, and initial glucose level were predictors of early recanalization (p<0.001). Recanalization status and initial NIHSS score were strongly correlated with a favorable outcome (p<0.005). CONCLUSIONS: This is the first report of the clinical profiles, outcomes, and their predictors in a cohort of Korean patients with AILAO.

Trombosis venosa cerebral en un paciente con disgerminoma en tratamiento quimioterápico / Cerebral venous thrombosis in a chemotherapy patient with dysgerminoma

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Accidente cerebrovascular recurrente y adenocarcinoma mucinoso de páncreas / Mucin-secretine adenocarcinomas of pancreatobiliary origin, hypercoagulable states and stroke

El adenocarcinoma mucinoso de páncreas se caraacteriza por su rápido crecimiento, su alta mortalidad y su frecuente asociación a los síndromes de hipercoagulabilidad. Sin embargo, el accidente cerebrovascular recurrente (ACV) como manifestación inicial, es excepcional. Se prestenta un paciente masculino de 57 años con diagnóstico de adenocarcinoma mucinoso de probable origen pancreático con diseminación hepática, que presentó ACV múltiples. En la resonancia magnética nuclear (RMN) de encéfalo inicial se constató una lesión isquémica aguda temporoparietal izquierda, y desarrolló lesiones isquémicas agudas en diversos territorios vasculares. Ante la sospecha de síndrome de Trousseau, un síndrome paraneoplásico de hipercoagulabilidad y fenómenos trombóticos, se solicitó un ecocardiograma transesofágico que descartó focos embolígenos cardíacos (endocarditis trombótica no bacteriana o ETNB) pero visualizó pequeñas placas fibrocálcicas en el cayado aórtico. Este caso ilustra la asociación sinérgica de síndrome de Trousseau y embolias del cayado aórtico en un paciente con ACV recurrente multifocal y adenocarcinoma mucinoso.

Primary systemic amyloidosis with ischemic stroke as a presenting complication.

BACKGROUND: Amyloidosis is an uncommon disorder that ultimately leads to fatal multiorgan failure. Ischemic strokes have been sporadically described but are not well characterized. The purpose of this study was to review the pathophysiologic relationship between primary systemic amyloidosis and ischemic stroke, and to determine how often stroke is the first defining manifestation. METHODS: Retrospective study of 49 patients with confirmed primary amyloidosis and ischemic stroke. All included patients had biopsy proven amyloidosis. RESULTS: Forty patients were included in the study. Ischemic strokes occurred in 13 patients (32.5%) as the initial presentation of amyloidosis. Patients with initial stroke presentation had the worst outcome, with average survival of 6.9 months after established diagnosis with amyloidosis; strokes developed 9.6 months before diagnosis with primary amyloidosis. Thirty-seven percent experienced recurrent ischemic stroke. The majority (70%) of patients had cardioembolic infarctions. CONCLUSIONS: Ischemic stroke is an underappreciated complication of primary amyloidosis. In the absence of obvious clinical and cardiogenic manifestations, primary amyloidosis should be considered when echocardiography demonstrates thickening of the valves, restrictive pattern, and increased echogenicity. Ischemic strokes as an initial presentation of primary amyloidosis carries a worse prognosis.

Plaque rupture in the carotid artery is localized at the high shear stress region: a case report.

BACKGROUND AND PURPOSE: Cerebrovascular events are related to atherosclerotic disease in the carotid arteries and are frequently caused by rupture of a vulnerable plaque. These ruptures are often observed at the upstream region of the plaque, where the wall shear stress (WSS) is considered to be highest. High WSS is known for its influence on many processes affecting tissue regression. Until now, there have been no serial studies showing the relationship between plaque rupture and WSS. Summary of Case- We investigated a serial MRI data set of a 67-year-old woman with a plaque in the carotid artery at baseline and an ulcer at 10-month follow up. The lumen, plaque components (lipid/necrotic core, intraplaque hemorrhage), and ulcer were segmented and the lumen contours at baseline were used for WSS calculation. Correlation of the change in plaque composition with the WSS at baseline showed that the ulcer was generated exclusively at the high WSS location. CONCLUSIONS: In this serial MRI study, we found plaque ulceration at the high WSS location of a protruding plaque in the carotid artery. Our data suggest that high WSS influences plaque vulnerability and therefore may become a potential parameter for predicting future events.

Frequent atrial premature beats predict paroxysmal atrial fibrillation in stroke patients: an opportunity for a new diagnostic strategy.

BACKGROUND AND PURPOSE: For patients having suffered ischemic stroke, the current diagnostic strategies often fail to detect atrial fibrillation as a potential cause of embolic events. The aim of the study was to identify paroxysmal atrial fibrillation in stroke patients. We hypothesized that patients with frequent atrial premature beats (APBs) recorded in 24-hour ECG will show more often atrial fibrillation when followed by repeated long-term ECG recordings than patients without or infrequent APBs. METHODS: 127 patients with acute ischemic stroke and without known AF were enrolled in a prospective study to detect paroxysmal AF. Patients were stratified according to the number of APBs recorded in a 24-hour ECG (> or =70 APBs versus <70 APBs). Subsequently, they all underwent serial 7-day event-recorder monitoring at 0, 3, and 6 months. RESULTS: Serial extended ECG monitoring identified AF in 26% of patients with frequent APBs but only in 6.5% when APBs were infrequent (P=0.0021). A multivariate analysis showed that the presence of frequent APBs in the initial 24-hour ECG was the only independent predictor of paroxysmal AF during follow-up (odds ratio 6.6, 95% confidence intervals 1.6 to 28.2, P=0.01). CONCLUSIONS: In patients with acute ischemic stroke, frequent APBs (> or = 70/24 hours) are a marker for individuals who are at greater risk to develop or have paroxysmal AF. For such patients, we propose a diagnostic workup with repeated prolonged ECG monitoring to diagnose paroxysmal AF.

Cerebral protection during retrograde carotid artery stenting for proximal carotid artery stenosis: technical note.

Carotid artery stenting for carotid bifurcation stenosis usually uses the transfemoral approach. However, in patients with proximal common carotid artery (CCA) stenosis, the guiding catheter is difficult to introduce into the narrow origin of the CCA without risking cerebral embolization before activation of the protection device. A technique of cerebral protection by internal carotid artery (ICA) clamping with or without simultaneous external carotid artery (ECA) clamping was used to treat patients with proximal CCA stenosis by the retrograde direct carotid approach. The carotid bifurcation was surgically exposed and retrograde catheterization was performed to approach the stenosis. The ICA was clamped during angioplasty and stenting to avoid cerebral embolization. The ECA was clamped simultaneously if any extracranial-intracranial anastomosis was present. None of five patients treated with this technique experienced ischemic complications attributable to this technique.

Correlation between carotid intraplaque hemorrhage and clinical symptoms: systematic review of observational studies.

BACKGROUND AND PURPOSE: We sought to investigate the association between carotid intraplaque hemorrhage (IPH) and ipsilateral symptoms of cerebral ischemia. METHODS: A search was performed for clinical observational studies comparing the incidence of IPH between symptomatic and asymptomatic patients. Odds ratios (ORs) for IPH as a factor in the pathogenesis of neurologic events were calculated and combined by a meta-analysis. Interstudy heterogeneity, estimated effects, and methodologic quality of the studies were assessed. RESULTS: Thirty-one studies were included for analysis. The reported ORs varied widely. Overall, the incidence of IPH in the symptomatic groups was significantly higher than in the asymptomatic group. However, there was an apparent trend for heterogeneity (P<0.00001) between studies. The random-effects summary estimator of ORs was 2.25 (95% CI, 1.57 to 3.22; P<0.00001). To identify potential sources of heterogeneity, subgroup analyses were performed. The pooled ORs varied greatly by stratification. Major heterogeneity was found among studies with low quality, microscopic methods of examination, significant effects, small sizes, early publication, and unequal severity of carotid stenosis in both groups. Large, recent, macroscopic, or high-quality studies, as well as studies with equal degrees of stenosis, tended to yield insignificant associations. The methods in defining and evaluating hemorrhage were very heterogeneous. Characterizations of the age, size, number, and location of hemorrhages were poorly reported and highly variable. In addition, a lack of control of confounders and selection bias were frequently identified among studies. CONCLUSIONS: Statistical inferences have suggested a plausible role in the production of cerebral ischemia; however, reliable interpretation was strongly undermined by poor methodologic quality, substantial heterogeneity, and suspicious publication bias. To preciously estimate the underlying correlation, a well-designed study with uniformity in definition and evaluation for IPH might be warranted.

Risk of acute brain injury related to cerebral microembolism during cardiac catheterization performed by right upper limb arterial access.

BACKGROUND AND PURPOSE: The primary objective of this study was to assess the incidence of new cerebral infarcts related to cardiac catheterization in patients explored through the right transradial approach. METHODS: This prospective study involved 41 consecutive patients with severe aortic valve stenosis. To assess the incidence of cerebral infarction, all patients underwent cerebral diffusion-weighted MRI before and after cardiac catheterization through the right transradial approach. RESULTS: We detected only two patients (4.9%) with new, small, isolated acute cerebral diffusion abnormalities postcatheterization. All patients remained asymptomatic. CONCLUSIONS: New cerebral lesions on diffusion-weighted MRI are infrequent in patients explored through the right transradial approach. Randomized studies are warranted to confirm for potential advantages of transradial approach versus the femoral approach in cardiac catheterization.