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1.
Eur J Vasc Endovasc Surg ; 59(4): 516-524, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32081531

RESUMO

OBJECTIVE: This study investigates the prognostic significance of pre-operative symptom status and type of symptom in outcomes after carotid endarterectomy (CEA). METHODS: This review was conducted and reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) to identify studies reporting peri-operative outcomes of CEA in symptomatic and asymptomatic patients. The last search was conducted in August 2019 and a methodological assessment was performed using the Newcastle Ottawa Scale. A meta-analysis of outcome data using the odds ratio (OR) as the summary statistic was conducted, and the precision of the effect was reported as 95% confidence interval (CI). Fixed effect or random effects models were used to calculate the pooled estimates. RESULTS: Eighteen studies reporting a total of 91 895 patients were included in the meta-analysis. Asymptomatic patients had a lower peri-operative risk of stroke (OR 0.5, 95% CI 0.45-0.54; p < .001) and death (OR 0.66, 95% CI 0.57-0.77; p < .001) than symptomatic patients, but the risk of myocardial infarction was not significantly different (OR 0.98, 95% CI 0.84-1.15; p = .82). Those suffering a pre-procedural stroke had an increased peri-operative risk of stroke and death vs. patients suffering a pre-procedural transient ischaemic attack or amaurosis fugax. CONCLUSION: Patients undergoing CEA after a stroke have worse peri-operative outcomes in terms of stroke and death. Further research needs to be performed to ascertain the value of this finding in risk stratification systems and to investigate potential aetiological associations between pre-operative symptom status and peri-operative risk following a CEA.


Assuntos
Amaurose Fugaz/diagnóstico , Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas/efeitos adversos , Ataque Isquêmico Transitório/diagnóstico , Complicações Pós-Operatórias/diagnóstico , Avaliação de Sintomas , Amaurose Fugaz/etiologia , Estenose das Carótidas/complicações , Estenose das Carótidas/mortalidade , Humanos , Ataque Isquêmico Transitório/etiologia , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/etiologia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Período Pré-Operatório , Prognóstico , Medição de Risco/métodos , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Fatores de Tempo , Resultado do Tratamento
2.
Medicine (Baltimore) ; 99(2): e18675, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31914059

RESUMO

BACKGROUND: The efficacy of patent foramen ovale (PFO) closure remains controversial, and it is unclear which patient groups are best benefited. We performed this meta-analysis to clarify the efficacy of PFO closure of younger patients for prevention of recurrent ischemic neurological events. METHODS: We systematically searched for studies of PFO closure for younger patients under the age of 55, and pooled available data on PFO closure of younger vs older patients and on PFO closure of younger patients vs medical therapy. The primary endpoints were the composite outcome of recurrent ischemic neurological events [stroke and/or transient ischemic attack (TIA)]. The secondary endpoints included recurrent stroke, TIA, atrial fibrillation (AF) and bleeding events. We calculated the odds ratios (OR) and 95% confidence interval (CI) using fixed-effect and random-effect models. RESULTS: Three randomized controlled trials (RCT) and 13 observational studies were eligible. Compared with older patients undergoing PFO closure, younger patients undergoing closure had a lower risk of composite outcome (OR: 0.40, 95% CI: 0.28 to .56; P < .001) and AF (OR: 0.25, 95% CI: 0.10-0.61; P = .003). Compared with medical therapy, PFO closure of younger patients reduced the risk of composite outcome (OR: 0.50, 95% CI: 0.33-0.75; P<.001); there was no statistical difference in total complications of AF and bleeding events (OR: 2.15, 95% CI: 0.15-30.37; P = .57). Separate analysis of stroke and TIA showed that PFO closure in younger patients was more effective in preventing stroke (OR: 0.45, 95% CI: 0.28-0.72; P < .001) and TIA (OR: 0.35, 95% CI: 0.21-0.58); P < .001) compared with older patients. Compared with medical therapy, PFO closure of younger patients reduced the risk of stroke (OR: 0.26, 95% CI: 0.13-0.51; P < .001); but there was no difference in the risk of TIA (OR: 1.07, 95% CI: 0.16-7.01; P = .94). CONCLUSIONS: Compared with PFO closure of older patients and medical therapy, PFO closure of younger patients can benefit more for the prevention of recurrent ischemic neurological events. Our results indicate that PFO closure is the best treatment strategy for younger patients under the age of 55.


Assuntos
Forame Oval Patente/cirurgia , Ataque Isquêmico Transitório/prevenção & controle , Acidente Vascular Cerebral/prevenção & controle , Adulto , Fatores Etários , Fibrilação Atrial/etiologia , Fibrilação Atrial/prevenção & controle , Feminino , Forame Oval Patente/complicações , Humanos , Ataque Isquêmico Transitório/etiologia , Masculino , Pessoa de Meia-Idade , Acidente Vascular Cerebral/etiologia , Fatores de Tempo
3.
J Stroke Cerebrovasc Dis ; 29(2): 104528, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31806451

RESUMO

BACKGROUND: Elevated high-sensitivity cardiac troponin T (hs-cTnT) levels have been related to clinical outcome in stroke patients. However, the role of hs-cTnT and its potential as a biomarker in ischaemic stroke (IS) has not been well established. This study aims to determine whether basal hs-cTnT determination in the hyperacute phase of undetermined IS and transient ischaemic attack (TIA) can predict the cardioembolic aetiology and clinical outcome. METHODS: We prospectively studied 110 consecutive patients with undetermined acute IS and TIA. hs-cTnT levels were determined at hospital arrival. Large vessel stenosis/occlusion and previously known aetiologies at admission were exclusion criteria for this study. All patients were subjected to a complete aetiological evaluation. A 12-month follow-up was performed in all patients. The subtype of IS was evaluated following the SSS-TOAST criteria. We established two groups at admission: cardioembolic aetiology (group A) and noncardioembolic aetiologies (group B). RESULTS: The number of patients in each group was similar (group A: 52, 47.27%; group B, 58, 52.73%). Patients in group A had elevated hs-cTnT more frequently (61.54% versus 17.24%; P < .001). Group A patients had significantly higher mortality at 3 months (14.29% versus 1.82%, P = .025). In the multivariate analysis, elevated hs-cTnT was the only independent predictor of cardioembolic aetiology (odds ratio: 14.821; 95% confidence interval: 3.717-59.102, P < .001). CONCLUSION: Baseline hs-cTnT assessment in undetermined strokes and TIA during the hyperacute phase is independently associated with cardioembolic aetiology.


Assuntos
Isquemia Encefálica/etiologia , Cardiopatias/sangue , Embolia Intracraniana/etiologia , Ataque Isquêmico Transitório/etiologia , Acidente Vascular Cerebral/etiologia , Troponina T/sangue , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/mortalidade , Feminino , Cardiopatias/complicações , Cardiopatias/diagnóstico , Cardiopatias/mortalidade , Humanos , Embolia Intracraniana/diagnóstico , Embolia Intracraniana/mortalidade , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/mortalidade , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Regulação para Cima
4.
Stroke ; 51(1): 262-267, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31842722

RESUMO

Background and Purpose- Stroke Risk Analysis (SRA) comprises an algorithm for automated analysis of ECG monitoring, enabling the detection of paroxysmal atrial fibrillation (pxAF) and identifying patterns indicating a high risk of atrial fibrillation (R_AF). We compared Holter-enabled continuous ECG monitoring in combination with SRA (hSRA) with standard continuous ECG monitoring for pxAF detection in patients with acute ischemic stroke. Also, we sought to identify whether the detection of R_AF patterns during the first cycle (first 2 hours) of hSRA recording was associated with the detection of pxAF during the Stroke Unit stay. Methods- We enrolled 524 consecutive patients admitted in the Stroke Unit with acute ischemic stroke or transient ischemic attack with neither history of AF nor AF at admission into a prospective multicentric observational analytic clinical study with intrapatient comparison, who received both continuous ECG monitoring as well as hSRA up to 7 days. Investigators were blinded to hSRA results unless pxAF was detected on SRA. Results- Of the 524 consecutive acute stroke patients (median age, 70.0 years; 60% male; acute ischemic stroke 93%, transient ischemic attack 7%), 462 were eligible and included in the study. Among 462 patients with hSRA available for 66 hours, AF was documented by hSRA in 79 patients (17.1%). From this group, 45 AF cases (9.7%) were confirmed after review by an independent and blinded cardiologist. continuous ECG monitoring detected 21 AF cases (4.3%; P<0.0001). hSRA detected R_AF patterns in 92 patients. 35 out of the 92 R_AF patients showed an episode of AF during the Stroke Unit stay. Predictive values of R_AF patterns within the first cycle of hSRA were: sensitivity 71%, specificity 86%, positive predictive value 38%, and negative predictive value 96%. Conclusions- Automated analysis using SRA technology strongly improves pxAF detection in acute ischemic stroke patients compared with continuous ECG monitoring. The predictive value of a R_AF pattern, as detected by hSRA during the first few hours after admission, deserves further investigation.


Assuntos
Fibrilação Atrial/fisiopatologia , Eletrocardiografia , Ataque Isquêmico Transitório/fisiopatologia , Acidente Vascular Cerebral/fisiopatologia , Idoso , Fibrilação Atrial/complicações , Fibrilação Atrial/terapia , Feminino , Humanos , Ataque Isquêmico Transitório/etiologia , Ataque Isquêmico Transitório/terapia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Medição de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/terapia
5.
Heart Surg Forum ; 22(5): E385-E389, 2019 Sep 16.
Artigo em Inglês | MEDLINE | ID: mdl-31596717

RESUMO

BACKGROUND: The aim of this study was to evaluate the frequency of postoperative complications in patients who underwent coronary artery bypass grafting (CABG) and simultaneous carotid endarterectomy (CEA) and find predictors of postoperative complications. METHODS: We retrospectively evaluated 86 patients after simultaneous CABG and CEA. Inclusion criteria were: patients with asymptomatic carotid stenosis with a reduction of the carotid lumen diameter of more than 70% detected with Doppler ultrasound and diagnosed with one, two, or three vessel coronary artery disease with coronary stenosis more than 75% and hemodynamic significant stenosis of the left main artery. Exclusion criteria were patients with urgent and previous cardiac surgery and patients with myocardial infarction and stroke in the past one month. We monitored preoperative (ejection fraction, coronarography status), operative (number of grafts, on-pump or off-pump technique) and postoperative (extubation, unit care and hospital stay, bleeding and reoperation) details and complications (myocardial infarction, neurological events, inotropic agents and transfusion requiry, infection, arrhythmic complication, renal failure, mortality). RESULTS: Postoperative complications were observed in 18 (29.9%) patients. Two patients (2.3%) had postoperative stroke and one patient (1.2%) had transient ischemic attack (TIA). Previous stroke was a predictor for increased postoperative neurological events (P < .05). Intrahospital mortality was 8.1%. CONCLUSION: Simultaneous CEA and CABG were performed with low rates of stroke and TIA. Previous stroke was identified as a predictor for increased postoperative neurological complications.


Assuntos
Estenose das Carótidas/cirurgia , Ponte de Artéria Coronária/efeitos adversos , Estenose Coronária/cirurgia , Endarterectomia das Carótidas/efeitos adversos , Complicações Pós-Operatórias/etiologia , Idoso , Arritmias Cardíacas/epidemiologia , Arritmias Cardíacas/etiologia , Doenças Assintomáticas , Estenose das Carótidas/complicações , Causas de Morte , Comorbidade , Estenose Coronária/complicações , Feminino , Humanos , Ataque Isquêmico Transitório/epidemiologia , Ataque Isquêmico Transitório/etiologia , Masculino , Mediastinite/epidemiologia , Mediastinite/etiologia , Complicações Pós-Operatórias/epidemiologia , Hemorragia Pós-Operatória/epidemiologia , Hemorragia Pós-Operatória/etiologia , Insuficiência Renal/epidemiologia , Insuficiência Renal/etiologia , Estudos Retrospectivos , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia
6.
J Stroke Cerebrovasc Dis ; 28(12): 104397, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31582273

RESUMO

AIM OF THE STUDY: Diffusion-weighted image (DWI) of magnetic resonance imaging (MRI) can reveal high signal lesion in up to 50% of transient ischemic attack (TIA) patients. However, it is not well-known which factors determine developing DWI positivity. In order to answer this question, we analyzed factors relevant to DWI positivity in TIA patients. METHODS: We had 257 stroke patients at a university emergency/neurology wards. They were 140 men, 117 women, mean age 72 (45-88) years. Among them, 24 (9.3%) had TIA (14 men, 10 women, mean age 71 [58-82] years). All patients underwent a 1.5T MRI. In 24 TIA patients, we investigated the following parameters in relation with stroke maturation: ABCD2 score, smoking habits, blood profile, HbA1C, dyslipidemia, coagulation factors, carotid echography, electrocardiography, cardiac echography, chest X-ray, neurological symptom/signs, imaging, and recurrence of neurological symptom on follow-up. RESULTS: In 24 TIA patients, 13 (54%) were DWI positive and 11 (46%) were DWI negative. After an extensive analysis, all parameters were not relevant to DWI positivity except for plasma osmolarity, i.e., plasma osmolarity in DWI positive cases (305.3 mOsm/l) is significantly higher than that in DWI negative cases (301.3 mOsm/l) (P = .0064). As for recurrence, 4 of 24 TIA patients recurred. They were 1 (9.0%) of 11 DWI negative cases and 3 (23.1%) of 13 DWI positive cases. Therefore, DWI positive cases recurred more frequently than DWI negative cases did, although it did not reach statistical significance. CONCLUSIONS: TIA with DWI positivity in our institute was 54%, closely associated with initial dehydration and might predict stroke recurrence.


Assuntos
Desidratação/complicações , Imagem de Difusão por Ressonância Magnética , Ataque Isquêmico Transitório/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Desidratação/sangue , Desidratação/diagnóstico , Desidratação/fisiopatologia , Feminino , Humanos , Ataque Isquêmico Transitório/sangue , Ataque Isquêmico Transitório/etiologia , Masculino , Pessoa de Meia-Idade , Estado de Hidratação do Organismo , Concentração Osmolar , Valor Preditivo dos Testes , Recidiva , Medição de Risco , Fatores de Risco
7.
J Stroke Cerebrovasc Dis ; 28(12): 104440, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31611167

RESUMO

Carotid artery web has been frequently reported. However, the vertebral artery web has been less reported. It is difficult and seldom to diagnose vertebral artery web with noninvasive examinations. Here, we present a case of asymptomatic vertebral artery web diagnosed by ultrasound and confirmed by digital subtraction angiography.


Assuntos
Angiografia Digital , Ultrassonografia Doppler em Cores , Malformações Vasculares/diagnóstico por imagem , Artéria Vertebral/diagnóstico por imagem , Feminino , Humanos , Ataque Isquêmico Transitório/etiologia , Pessoa de Meia-Idade , Paresia/etiologia , Valor Preditivo dos Testes , Prognóstico , Malformações Vasculares/complicações , Malformações Vasculares/fisiopatologia , Malformações Vasculares/terapia , Artéria Vertebral/anormalidades , Artéria Vertebral/fisiopatologia
8.
Zhongguo Yi Xue Ke Xue Yuan Xue Bao ; 41(4): 457-463, 2019 Aug 30.
Artigo em Chinês | MEDLINE | ID: mdl-31484606

RESUMO

To systematically evaluate the risks of cardiocerebral vascular events in patients with primary biliary cholangitis(PBC). Methods We carried out a Meta analysis by RevMan 5.3 software to investigate literatureon the risk of cardiocerebral vascular events in patients with PBC and controls. Results Compared with non-PBC controls,PBC patients had significantly higher risk of coronary events(RR=1.56,P=0.0002);however,the risk of cerebrovascular events showed no significant difference between these two groups(RR=1.01,P=0.94).Subgroup analysis demonstrated a significantly lower risk of transient ischemic attack or carotid stenosis in PBC patients(RR=0.63,P=0.03);however,there was no significant difference in the risk of stroke(RR=1.11,P=0.40). Conclusion Patients with PBC have an increased risk of coronary events but may have a lower risk of transient ischemic attack or carotid stenosis.


Assuntos
Colangite/complicações , Doença das Coronárias/etiologia , Cirrose Hepática Biliar/complicações , Estenose das Carótidas/etiologia , Humanos , Ataque Isquêmico Transitório/etiologia , Fatores de Risco , Acidente Vascular Cerebral/etiologia
9.
Ideggyogy Sz ; 72(7-8): 241-256, 2019 Jul 30.
Artigo em Inglês | MEDLINE | ID: mdl-31517456

RESUMO

Background and purpose: The aim of this study is to evaluate utility of CHADS2 score to estimate stroke severity and prognosis in patients with ischemic stroke due to non-valvular atrial fibrillation (AF) in addition to evaluate effects of hematologic and echocardiographic findings on stroke severity and prognosis. Methods: This prospective study included 156 ischemic stroke cases due to non-valvular AF in neurology ward of Trakya University Medical School between March 2013-March 2015. National Institute of Health Stroke (NIHS) score was used to evaluate severity of stroke at admission. Carotid and vertebral Doppler ultrasonography findings, brain computed tomography (CT) and magnetic resonance imaging (MRI) of the cases were evaluated. Left atrial diameter and ejection fraction (EF) values were measured. CHADS2 score was calculated. Modified Rankin Scale was used to rate the degree of dependence. Effects of age and sex of the patients, presence of diabetes mellitus (DM), Congestive Heart Failure (CHF), Cerebrovascular Disease (CVD) and C-reactive protein (CRP) levels on CHADS2, NIHS, and mRS were evaluated. Results: In patients with age ≥75, mean NIHS score was 3.3 points and mean mRS score was 1.02 points higher, than in patient below 75 years of age. Compared with the mild risk group, cases in the high risk group had older age, higher serum D-dimer, fibrinogen and CRP levels and lower EF. A positive relation was detected between stroke severity and Hemorrhagic Transformation (HT), previous CVD history, and presence of CHF. A significant association was found between increased stroke severity and Early Neurological Deterioration (END) development. Older age, higher serum fibrinogen, D-dimer, CRP and lower EF values were associated with poor prognosis. History of CVD and presence of CHF were associated with poor prognosis. END development was found to be associated with poor prognosis. In the high-risk group, 30.3% (n = 33) had END. Among those in the high-risk group according to the CHADS2 score, END development rate was found to be significantly higher than in the moderate risk group (p <0.05). There was a strong positive correlation between CHADS2 and NIHS scores. mRS score increased with increasing CHADS2 score and there was a strong correlation between them. Effect of stroke severity on prognosis was assessed and a positive correlation was found between NIHS score and mRS value. Conclusion: Our study demonstrated the importance of CHADS2 score, haemostatic activation and echocardiographic findings to assess stroke severity and prognosis. Knowing factors which affect stroke severity and prognosis in patients with ischemic stroke may be directive to decide primary prevention and stroke management.


Assuntos
Fibrilação Atrial/complicações , Ecocardiografia , Insuficiência Cardíaca/complicações , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/epidemiologia , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Idoso , Fibrilação Atrial/sangue , Humanos , Ataque Isquêmico Transitório/etiologia , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Acidente Vascular Cerebral/sangue , Acidente Vascular Cerebral/etiologia
11.
Heart Surg Forum ; 22(4): E301-E307, 2019 07 25.
Artigo em Inglês | MEDLINE | ID: mdl-31398097

RESUMO

BACKGROUND: Antiplatelet therapy is critical in the management of coronary artery diseases. For patients undergoing cardiac surgeries, including coronary artery bypass graft (CABG) and valve replacement, controversy remains in preoperative antiplatelet therapy concerning risk of bleeding. For safety concern, aspirin is recommended to be withdrawn 5 to 10 days before a cardiac surgery. Recent studies, however, indicate that preoperative aspirin may have a protective effect on cardiac surgery-associated acute kidney injury (CSA-AKI). OBJECTIVE: To estimate the efficacy of preoperative aspirin in preventing CSA-AKI. METHODS AND RESULTS: Eligible studies included randomized controlled trials (RCTs) and observational studies (OSs) of patients, who had undergone CABG, valve replacement, or combined surgery. These studies compared preoperative aspirin with placebo/no aspirin and reported the least incidence of CSA-AKI. One RCT and five OSs met the inclusion criteria. Data retrieved suggested that aspirin prescribed within five days before cardiac surgery decreased post-operative renal failure [odds ratio (OR), 0.67; 95% confidence interval (CI), 0.50-0.89; P < 0.01] and 30-day mortality (OR, 0.64; 95% CI, 0.53-0.77; P < 0.01). One RCT and three OSs suggested aspirin protected from major adverse cardiocerebral events (MACE) (OR, 0.88; 95% CI, 0.76-1.01; P = 0.07). One RCT and two OSs suggested aspirin did not increase risk of re-exploration for bleeding (OR, 1.01; 95% CI, 0.76-1.34; P = 0.95). CONCLUSION: Preoperative low-dose aspirin decreases post-operative CSA-AKI, mortality, and MACE without increasing the risk of re-exploration. But most of the studies are observational. They lack a uniformed standard on prescription of aspirin and outcomes measurement. No stratification analysis is performed concerning different types of surgical procedures and comorbidities. More randomized controlled trials are necessary to confirm the efficacy and safety of preoperative aspirin prescription.


Assuntos
Lesão Renal Aguda/prevenção & controle , Aspirina/administração & dosagem , Ponte de Artéria Coronária/efeitos adversos , Implante de Prótese de Valva Cardíaca/efeitos adversos , Inibidores da Agregação de Plaquetas/administração & dosagem , Complicações Pós-Operatórias/prevenção & controle , Causas de Morte , Coma/etiologia , Parada Cardíaca/etiologia , Bloqueio Cardíaco/etiologia , Humanos , Ataque Isquêmico Transitório/etiologia , Infarto do Miocárdio/etiologia , Estudos Observacionais como Assunto , Complicações Pós-Operatórias/etiologia , Ensaios Clínicos Controlados Aleatórios como Assunto
12.
Saudi Med J ; 40(7): 721-726, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31287134

RESUMO

Parry-Romberg syndrome is a rare disorder with progressive hemifacial atrophy of unknown etiology. We reported 2 cases of progressive hemifacial atrophy with different neurological manifestations from Kuwait. The first case was a 14-year-old boy who initially presented with recurrent transient stroke-like episodes followed by focal seizures and hemifacial atrophy. Magnetic resonance imaging showed significant white matter changes and cerebral hemiatrophy. The second case was a 7-year-old girl who presented with complex partial seizures and hemifacial atrophy, her magnetic resonance imaging scan showed minimal changes in the hemiatrophy of the temporal cerebral lobe. Both patients' disease activity was well controlled with immunosuppressive therapy and anticonvulsants. Parry-Romberg syndrome should be considered in any child with unexplained neurological symptoms.


Assuntos
Cérebro/diagnóstico por imagem , Epilepsias Parciais/fisiopatologia , Hemiatrofia Facial/fisiopatologia , Ataque Isquêmico Transitório/fisiopatologia , Adolescente , Anticonvulsivantes/uso terapêutico , Atrofia , Cérebro/patologia , Criança , Eletroencefalografia , Epilepsias Parciais/tratamento farmacológico , Epilepsias Parciais/etiologia , Hemiatrofia Facial/complicações , Hemiatrofia Facial/diagnóstico por imagem , Hemiatrofia Facial/tratamento farmacológico , Feminino , Glucocorticoides/uso terapêutico , Humanos , Imunossupressores/uso terapêutico , Ataque Isquêmico Transitório/etiologia , Kuweit , Imagem por Ressonância Magnética , Masculino , Metotrexato/uso terapêutico , Prednisolona/uso terapêutico
13.
Int Angiol ; 38(4): 320-325, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31203595

RESUMO

BACKGROUND: Several techniques of carotid endarterectomy have been described and currently used in clinical practice. We describe and report the midterm results of short non-patch arteriotomy technique. METHODS: We analyzed patients treated at our Department for carotid artery stenosis. Main outcomes were mortality, stroke, restenosis and local complications. The technique consists in a short longitudinal arteriotomy from common carotid artery to internal (ICA), followed by thromboendarterectomy in carotid bulb with a blunt spatula, cutting the more proximal edge of the plaque. A semi-eversion is then performed in the ICA to fully remove carotid plaque. RESULTS: In the period between years 2011-2016 we performed 476 carotid endarterectomies of which 436 with short non-patch arteriotomy. Mean clamping time was 15.5±5.7 minutes. In-hospital complications were: three cases of stroke (0.7%), all with complete recovery, four transient cerebral ischemia (0.9%), 14 cervical hematomas (3.2%), and four cranial nerve injuries (0.9%), which was in all cases completely regressed. At two years, we report six cases of carotid restenosis (1.4%), all treated with carotid stenting. CONCLUSIONS: Short non-patch carotid endarterectomy technique resulted in a low mid-term rates of stroke, restenosis, and cranial nerve injuries compared to other surgical series in the literature.


Assuntos
Artéria Carótida Interna/cirurgia , Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas , Stents , Idoso , Idoso de 80 Anos ou mais , Estenose das Carótidas/mortalidade , Angiografia por Tomografia Computadorizada , Traumatismos dos Nervos Cranianos/etiologia , Bases de Dados Factuais , Feminino , Humanos , Ataque Isquêmico Transitório/etiologia , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Taxa de Sobrevida , Fatores de Tempo , Resultado do Tratamento
14.
J Vasc Surg ; 69(6): 1801-1806, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31159983

RESUMO

OBJECTIVE: Patch angioplasty has been shown to decrease rates of restenosis after carotid endarterectomy (CEA). In 2003, the Vascular Study Group of New England (VSGNE) implemented its first quality initiative aimed at increasing the rates of patch closure after CEA. This study reports the effects of that initiative on the rate of patch closure in the VSGNE and also postoperative and 1-year CEA outcomes. METHODS: Patients undergoing CEA (N = 14,636) within the VSGNE between 2003 and 2014 were studied. Rates of in-hospital postoperative events (death, ipsilateral stroke or transient ischemic attack [TIA], and return to the operating room for bleeding) and events during 1 year of follow-up (stroke or TIA and restenosis >70% or occlusion) were compared by repair type-patch closure, primary closure, or eversion. One-year follow-up events were also compared over time and by annualized surgeon volume. RESULTS: During the 12 years studied, patch use increased from 71% to 91% (P < .001). There was no difference in postoperative death or ipsilateral stroke or TIA between the repair types. However, there was a statistically lower rate of return to the operating room for bleeding (P < .001), 1-year stroke or TIA (P < .003), and 1-year restenosis or occlusion (P < .001) with patch closure. Overall, the rates of 1-year stroke or TIA and restenosis decreased over time in the VSGNE. The initiative affected patch closure rates and outcomes of high-volume surgeons (>47 CEAs/y) the most. High-volume surgeons increased patch use from 50% to 90% and decreased their restenosis rates from 9.0% to 1.2% and 1-year stroke or TIA from 4.9% to 1.9% (P < .001). CONCLUSIONS: The VSGNE carotid patch quality initiative successfully increased the rates of CEA patch closure. During the same time, there has been a decrease in postoperative bleeding requiring reoperation and 1-year ipsilateral neurologic events and restenosis or occlusion.


Assuntos
Angioplastia/instrumentação , Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas , Idoso , Angioplastia/efeitos adversos , Angioplastia/mortalidade , Estenose das Carótidas/complicações , Estenose das Carótidas/mortalidade , Bases de Dados Factuais , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/mortalidade , Feminino , Humanos , Ataque Isquêmico Transitório/etiologia , Ataque Isquêmico Transitório/mortalidade , Masculino , New England , Hemorragia Pós-Operatória/mortalidade , Hemorragia Pós-Operatória/cirurgia , Recidiva , Reoperação , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Resultado do Tratamento
15.
Ann R Coll Surg Engl ; 101(8): 579-583, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31155910

RESUMO

INTRODUCTION: Isolated monocular ischaemic events are thought to be low risk for stroke recurrence. In the presence of carotid stenosis however, the risks should not be treated similarly and surgical intervention should be considered at an early stage. The aim of this study was to determine the vascular risk profile and stroke recurrence in patients with ischaemic monocular visual loss. METHODS AND METHODS: Consecutive records for all patients with monocular ischaemia were reviewed from January 2014 to October 2016. Stroke, transient ischaemic attack or monocular ischaemia recurrence within 90 days were recorded. Carotid stenosis was assessed with duplex ultrasound, computed tomography or magnetic resonance angiography. RESULTS: In total, 400 patients presented with monocular ischaemia; 391 had carotid imaging (97.8%). Causality was symptomatic carotid stenosis ≥ 50% in 53 (13.6%), including carotid stenosis ≥ 70% in 31 (7.9%). Patients with permanent visual loss (n = 131) were more likely to have significant stenosis compared with patients with transient visual loss (n = 260), 19.8% compared with 10.4% (P = 0.012). Recurrent stroke, transient ischaemic attack or monocular ischaemia within 90 days after presentation occurred in three patients (5.7%) in the carotid stenosis group, compared to three (0.9%) who did not have stenosis (P = 0.035). Age, male sex and hypertension were associated with carotid stenosis but hypercholesterolaemia, diabetes and smoking were not. CONCLUSIONS: Carotid stenosis ≥ 50% is present in patients with ocular ischaemia in approximately 20% of those with persistent visual loss and in 10% with transient visual loss. Those with carotid stenosis have a higher risk of stroke recurrence and should be considered urgent surgical intervention as other forms of stroke.


Assuntos
Amaurose Fugaz/etiologia , Estenose das Carótidas/complicações , Acidente Vascular Cerebral/etiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Cegueira/etiologia , Estenose das Carótidas/diagnóstico por imagem , Feminino , Humanos , Isquemia , Ataque Isquêmico Transitório/etiologia , Angiografia por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de Risco , Tomografia Computadorizada por Raios X/métodos , Ultrassonografia Doppler Dupla/métodos , Adulto Jovem
16.
J Stroke Cerebrovasc Dis ; 28(8): 2250-2254, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31171458

RESUMO

PURPOSE: Carotid occlusion may result in stroke, TIA, and cognitive reductions. Whether cognition predicts quality of life (QOL) for patients with carotid occlusion is unknown. Depression is also known to affect QOL. We examined whether cognition and depression predicted QOL in patients with carotid occlusive disease who have not had revascularization. METHODS: Patients with unilateral carotid occlusion and history of TIA or a remote history of minor stroke were included. Patients underwent exam of memory, language, motor, and executive function skills and completed depression and QOL questionnaires (Center for Epidemiological Studies-Depression [CES-D], Stroke Specific QOL [SSQOL]). Deficits from remote stroke were assessed with the NIH Stroke Scale (NIHSS). Z-scores for cognitive tests were averaged (Cog-Z). The SSQOL scores were averaged across subgroup domains. Analyses of patients with all depression levels were followed by subgroup analyses for patients with minimal depression. Correlation findings were used to select the variables in a regression model to predict SSQOL. RESULTS: Among 37 patients with all depression levels, QOL was predicted by deficits from remote stroke and depression (F(3, 36) = 21.15, P<.0005; NIHSS Beta = -.392, P = .001; CES-D Beta = -.577, P < .0005). Among 22 patients with minimal depression, QOL was predicted by cognitive and depression scores, (F(2,21) = 7.88, P = .003; Cog-Z Beta = .364, P = .05; CES-D Beta = -.495, P = .01). CONCLUSIONS: In patients with carotid occlusive disease without major stroke and without revascularization, cognitive and depression scores independently predicted QOL. These data demonstrate the clinical relevance of cognitive and mood decline among patients with carotid occlusion.


Assuntos
Afeto , Estenose das Carótidas/complicações , Transtornos Cognitivos/etiologia , Cognição , Depressão/etiologia , Qualidade de Vida , Adulto , Idoso , Estenose das Carótidas/diagnóstico , Estenose das Carótidas/psicologia , Transtornos Cognitivos/diagnóstico , Transtornos Cognitivos/psicologia , Depressão/diagnóstico , Depressão/psicologia , Feminino , Humanos , Ataque Isquêmico Transitório/etiologia , Ataque Isquêmico Transitório/psicologia , Masculino , Pessoa de Meia-Idade , Testes Neuropsicológicos , Prognóstico , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/psicologia , Inquéritos e Questionários , Fatores de Tempo
17.
J Vasc Surg ; 70(1): 274-284.e5, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31230646

RESUMO

OBJECTIVE: The direct thrombin inhibitor bivalirudin (BIV) was shown to be superior to unfractionated heparin (UFH) in percutaneous coronary interventions for reducing procedural blood loss. The aim of this study was to compare outcome profiles of BIV and UFH in peripheral endovascular procedures (PEPs) by synthesizing the currently available data. METHODS: Following the PRISMA statement, we conducted a comprehensive literature search using Medline, Cochrane CENTRAL, PubMed, EMBASE, CINAHL Google scholar, and clinicaltrials.gov. We recruited randomized, controlled trials and well-conducted observational studies that compared UFH and BIV in PEPs requiring anticoagulation, excluding endovascular cardiac procedures and coronary interventions. Random-effects meta-analyses were conducted to compare the outcome profiles of these two agents. RESULTS: Thirteen articles containing 17 studies involving a total of 21,057 patients were enrolled. Of these, 2 were randomized controlled trials, 2 were prospective cohort studies, and 10 were retrospective studies. There were no significant differences between BIV and UFH in terms of procedural success rates, major and minor perioperative bleeding, transfusion, perioperative transient ischemic attack, or hemorrhagic strokes. However, compared with UFH, BIV had significantly lower odds ratios (OR) of perioperative mortality (OR, 0.58; 95% confidence interval [CI], 0.40-0.86), major adverse cardiovascular events (OR, 0.65; 95% CI, 0.51-0.83), net adverse clinical events (OR, 0.75; 95% CI, 0.63-0.88), perioperative myocardial infarction (OR, 0.73; 95% CI, 0.55-0.98), major vascular complications (OR, 0.59; 95% CI, 0.39-0.91), and minor vascular complications (OR, 0.58; 95% CI, 0.40-0.84). CONCLUSIONS: Compared with UFH, PEPs using BIV had comparable procedural success rates and odds of perioperative transient ischemic attack and hemorrhagic stroke. However, procedures with BIV had a lower but nonsignificant odds of perioperative bleeding and transfusion. Depending on the procedures conducted, the patients who received BIV will have reduced or comparable odds of perioperative mortality, myocardial infarction, major adverse cardiovascular events, net adverse clinical events, and major and minor vascular complications. Therefore, BIV may be chosen solely as an alternative procedural anticoagulant to UFH for PEPs.


Assuntos
Anticoagulantes/uso terapêutico , Antitrombinas/uso terapêutico , Procedimentos Endovasculares , Heparina/uso terapêutico , Fragmentos de Peptídeos/uso terapêutico , Doenças Vasculares Periféricas/terapia , Anticoagulantes/efeitos adversos , Antitrombinas/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Hemorragia/induzido quimicamente , Heparina/efeitos adversos , Hirudinas/efeitos adversos , Humanos , Ataque Isquêmico Transitório/etiologia , Infarto do Miocárdio/etiologia , Estudos Observacionais como Assunto , Segurança do Paciente , Fragmentos de Peptídeos/efeitos adversos , Doenças Vasculares Periféricas/mortalidade , Ensaios Clínicos Controlados Aleatórios como Assunto , Proteínas Recombinantes/efeitos adversos , Proteínas Recombinantes/uso terapêutico , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Resultado do Tratamento
18.
Neurology ; 93(4): e388-e397, 2019 07 23.
Artigo em Inglês | MEDLINE | ID: mdl-31239360

RESUMO

OBJECTIVE: To identify independent predictors of clinical or cerebral lesion progression in a large sample of adult patients with moyamoya angiopathy (MMA) prior to decisions regarding revascularization surgery. METHODS: Ninety participants (median age, 37.5 years) were assessed at baseline and followed for a median time of 42.8 months. Incident ischemic and hemorrhagic strokes, death, as well as any incident ischemic and hemorrhagic lesions on MRI were recorded. Multiple demographic, clinical, and cerebral imaging measures at baseline were considered as potential predictors of clinical or cerebral tissue change at follow-up. Data were analyzed based on the Andersen-Gill counting process model, followed by internal validation of the prediction model. RESULTS: Among multiple potential predictive measures considered in the analysis, Asian origin, a history of TIAs, and a reduction in hemodynamic reserve, as detected by imaging, were found to be significantly associated with an increased risk of combined clinical and imaging events. While the model estimated the risk of clinical or cerebral lesion progression to be approximately 0.5% per year when none of these factors was present, this risk exceeded 20% per year when all factors were present. CONCLUSION: A simple combination of demographic, clinical, and cerebral perfusion imaging measures may aid in predicting the risk of incident stroke and cerebral lesion progression in adult patients with MMA. These results may help to improve therapeutic decisions and aid in the design of future trials in adults with this rare condition.


Assuntos
Hemorragias Intracranianas/etiologia , Ataque Isquêmico Transitório/etiologia , Doença de Moyamoya/fisiopatologia , Acidente Vascular Cerebral/etiologia , Adulto , Grupo com Ancestrais do Continente Africano/estatística & dados numéricos , Grupo com Ancestrais do Continente Asiático/estatística & dados numéricos , Revascularização Cerebral , Circulação Cerebrovascular , Tomada de Decisão Clínica , Progressão da Doença , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , França , Humanos , Masculino , Mortalidade , Doença de Moyamoya/complicações , Doença de Moyamoya/diagnóstico por imagem , Doença de Moyamoya/cirurgia , Prognóstico , Medição de Risco , Adulto Jovem
19.
Ann Vasc Surg ; 60: 229-235, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31075478

RESUMO

BACKGROUND: One of the most critical phases of carotid endarterectomy (CEA) is the carotid cross-clamping test, which is a concrete evaluation of efficacy of collateral cerebral perfusion. Some studies revealed a strong correlation between tolerance to carotid cross-clamping and postoperative transient ischemic attack (TIA)/stroke complications. The aim of the study is to make a global analysis of supra-aortic trunks (SAT) and circle of Willis (CoW) patency to predict the tolerance to carotid cross-clamping preoperatively. METHODS: We observed retrospectively 503 patients who underwent CEA under local anesthesia between January 2012 and 2017. We analyzed single preoperative risk factors, drug therapy, and vessels patency of the group of patients who did or did not present neurological symptoms at carotid cross-clamping. Afterward, we created a cerebral perfusion score (PTOT) to estimate the efficacy of collateral cerebral perfusion and we compared the results from both groups. The score ranges from 0 (hypothetical total occlusion of the SAT and CoW) to 0.65 in case of patency of all arterial districts. Moreover, we evaluated postoperative complication rates. RESULTS: Patients with previous neurological symptoms, female gender, and diabetes correlate with a lower tolerance to carotid cross-clamping (odds ratio: 2.57, 2.78, and 2.57, respectively; P value < 0.05). The SAT and CoW score revealed that patients with score <0.2 more frequently did not tolerate carotid cross-clamping (P value 0.01). Patients who required an intraoperative shunt presented a higher risk of TIA/stroke within 30 days from surgery than those with a better neurological compensation (P value 0.03). CONCLUSIONS: The efficacy of cerebral mechanisms of compensation during carotid cross-clamping reflects the capability of the brain to adapt to ischemic insults, and this also correlates with the postoperative risk of TIA/stroke. It is possible to identify preoperatively patients with a higher risk of neurological intolerance at carotid cross-clamping. This score could be a useful method to make a further stratification of risk of neurological complications and eventually to prefer a general anesthesia and the use of shunt for those with PTOT < 0.2.


Assuntos
Aorta/fisiopatologia , Doenças das Artérias Carótidas/cirurgia , Circulação Cerebrovascular , Círculo Arterial do Cérebro , Endarterectomia das Carótidas , Grau de Desobstrução Vascular , Idoso , Idoso de 80 Anos ou mais , Doenças das Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/fisiopatologia , Circulação Colateral , Constrição , Endarterectomia das Carótidas/efeitos adversos , Feminino , Humanos , Ataque Isquêmico Transitório/etiologia , Ataque Isquêmico Transitório/fisiopatologia , Masculino , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
20.
Neurol India ; 67(2): 364-369, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31085837

RESUMO

Background: Remarkable advancements in the understanding of etiological risk factors and pathophysiology of cerebrovascular diseases have led to the refining of definitions and terminologies in stroke medicine periodically. We aim to analyze the utility and meaning of different eponyms in the stroke medicine literature during the last 20 years. Materials and Methods: A systematic search was performed in Google Scholar for the words "stroke," "TIA," "cerebrovascular accident (CVA)," "cerebrovascular insult," "cerebrovascular event," "cerebral ischemia," and "cerebrovascular disease." Each of the words were searched yearwise from 1996 to 2015, and the numbers of articles using these words were collected and analyzed. Results: ": Stroke" has been the most common terminology used in literature, which showed a progressive increase in its usage until 2010, after which its use drastically reduced. "Cerebrovascular events" and "cerebral ischemia" are the second most commonly used terminologies with variable definitions; there was a steep increase in the use of these words until 2012. Conclusions: The most imprecise term that continues to be used is "CVA". The precisely defined entity like "cerebrovascular disease," which is a group of diseases, continues to be used inappropriately. All the terms are not defined uniformly across the globe, whereas most continue to use the World Health Organisation definition of stroke, defined in the 1970s. It is essential to condemn the use of imprecise terminologies and promote the use of recently defined precise terms "stroke" and "transient ischemic attack (TIA)". Unless the same terms with precise definitions are used in clinical practice or literature, the progress of stroke medicine will continue to be hampered.


Assuntos
Isquemia Encefálica/etiologia , Transtornos Cerebrovasculares/complicações , Ataque Isquêmico Transitório/etiologia , Acidente Vascular Cerebral/etiologia , Infarto Cerebral/complicações , Transtornos Cerebrovasculares/diagnóstico , Feminino , Humanos , Ataque Isquêmico Transitório/diagnóstico , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico
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