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1.
Angiol Sosud Khir ; 27(1): 164-168, 2021.
Artigo em Russo | MEDLINE | ID: mdl-33825744

RESUMO

This article describes a rare clinical and diagnostic case report regarding a female patient presenting with frequent transitory attacks in the basin of both middle cerebral arteries. Based on the findings of duplex scanning of the cervical arteries we revealed floating structures with the presence of pronounced slow turbulent blood flow. After excluding all known causes of cerebral artery microembolism, associated with heart pathology or with the presence of unstable atherosclerotic plaques, the leading hypothesis of transitory ischaemic attacks in the woman concerned was the formation of microthrombi in the zone of motility of the structures revealed. The results of bitemporal transcranial Doppler monitoring carried out during 30 minutes detected more than 10 microembolic signals in the middle cerebral artery, thus confirming the embolic nature of transitory ischaemic attacks.


Assuntos
Estenose das Carótidas , Ataque Isquêmico Transitório , Artérias Carótidas , Artérias Cerebrais , Feminino , Humanos , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/etiologia , Ultrassonografia Doppler Transcraniana
2.
Khirurgiia (Mosk) ; (3): 50-56, 2021.
Artigo em Russo | MEDLINE | ID: mdl-33710826

RESUMO

OBJECTIVE: To determine the most optimal period of surgical treatment after previous stroke. MATERIAL AND METHODS: There were 186 patients with significant ICA stenosis and previous unilateral stroke for the period 2008-2014 at the Pletnev Hospital (Moscow). Surgical approach was used in 136 (73.1%) patients (group I), conservative treatment at the neurological department - in 50 (26.9%) patients (group II). We analyzed neurological and cognitive status in both groups, regression of symptoms depending on the period after stroke, early and long-term postoperative outcomes. RESULTS: In early postoperative period, 7 (5.1%) cerebral ischemic events (transient ischemic attack (TIA) and stroke) occurred in the 1st group. No correlation of neurological complications and type of intervention was revealed. In long-term period, stroke occurred in 3.6% in the first group and in 14% in the second group over the same period. Surgical treatment was followed by more complete recovery of neurological functions (NIHSS score 6.2±0.5 versus 7.0±0.8; modified Rankin score 1.5±0.2 versus 2.1±0.5, p<0.05) and cognitive mechanisms (MoCA score 22.04±1.48 versus 20.04±1.48, p<0.05). CONCLUSION: Carotid endarterectomy and carotid artery stenting are effective for prevention of recurrent stroke. Carotid artery repair accelerates recovery of cognitive functions and regression of neurological symptoms in these patients.


Assuntos
Implante de Prótese Vascular , Estenose das Carótidas , Endarterectomia das Carótidas , Ataque Isquêmico Transitório , Acidente Vascular Cerebral , Estenose das Carótidas/complicações , Estenose das Carótidas/diagnóstico , Estenose das Carótidas/cirurgia , Tratamento Conservador , Endarterectomia das Carótidas/efeitos adversos , Humanos , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/etiologia , Fatores de Risco , Stents , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia , Resultado do Tratamento
3.
Int Heart J ; 62(2): 312-319, 2021 Mar 30.
Artigo em Inglês | MEDLINE | ID: mdl-33678799

RESUMO

This study aims to evaluate the incidence of ischemic stroke or transient ischemic attack (TIA) based on CHA2DS2-VASc scores in non-AF Chinese patients with sinus rhythm.We used health check-up data of 101,510 participants from the Kailuan Cohort Study. Participants' risk levels were defined by their CHA2DS2-VASc scores (range 0-3): Men with scores of 0, 1, or ≥ 2 and women with scores of 1, 2, or ≥ 3 were considered at low, intermediate, or high risk, respectively. Cox proportional hazards model was used to assess the association between the CHA2DS2-VASc-determined risk and the incidence of ischemic stroke/TIA.The mean 7.5 year follow-up examination revealed 2968 ischemic strokes/TIA events. The incidence rates for ischemic stroke/TIA events in men and women were 3.8% and 1.5%, respectively. The incidence of ischemic stroke/TIA increased with elevated predicted risks based on CHA2DS2-VASc scores in men: 2.2% for low-risk, 4.1% for intermediate-risk, and 7.8% for high-risk groups (P < 0.001 for trend). The incidences of ischemic stroke/TIA also increased with elevated predicted risks in women: 0.8% for low-risk, 2.1% for intermediate-risk, and 5.0% for high-risk groups (P < 0.001 for trend). Compared with low-risk group, the crude hazard ratio (95% confidence interval) of ischemic stroke/TIA for men in moderate- and high-risk groups were 1.96 (1.79-2.14; P < 0.001) and 4.18 (3.81-4.57; P < 0.001). Similar findings were observed in women.Risks of ischemic stroke/TIA events was high, particularly among those with high CHA2DS2-VASc scores.


Assuntos
Fibrilação Atrial/complicações , Isquemia Encefálica/epidemiologia , Frequência Cardíaca/fisiologia , Ataque Isquêmico Transitório/epidemiologia , Medição de Risco/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/etiologia , China/epidemiologia , Feminino , Humanos , Incidência , Ataque Isquêmico Transitório/etiologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
4.
Lancet Neurol ; 20(3): 193-202, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33609477

RESUMO

BACKGROUND: There is uncertainty around which patients with asymptomatic carotid stenosis should be offered surgical intervention. Although stroke rates were unrelated to the degree of stenosis in the medical-treatment-only groups in previous randomised trials, this could simply reflect recruitment bias and there has been no systematic analysis of a stenosis-risk association in cohort studies. We aimed to establish whether there is any association between the degree of asymptomatic stenosis and ipsilateral stroke risk in patients on contemporary medical treatment. METHODS: We did a prospective population-based study (Oxford Vascular Study; OxVasc), and a systematic review and meta-analysis. All patients in OxVasc with a recent suspected transient ischaemic attack or stroke, between April 1, 2002, and April 1, 2017, who had asymptomatic carotid stenosis were included in these analyses. We commenced contemporary medical treatment and determined ipsilateral stroke risk in this cohort by face-to-face follow-up (to Oct 1, 2020). We also did a systematic review and meta-analysis of all published studies (from Jan 1, 1980, to Oct 1, 2020) reporting ipsilateral stroke risk in patients with asymptomatic carotid stenosis. We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials, and included both observational cohort studies and medical treatment groups of randomised controlled trials if the number of patients exceeded 30, ipsilateral stroke rates (or the raw data to calculate these) were provided, and were published in English. FINDINGS: Between April 1, 2002, and April 1, 2017, 2354 patients were consecutively enrolled in OxVasc and 2178 patients underwent carotid imaging, of whom 207 had 50-99% asymptomatic stenosis of at least one carotid bifurcation (mean age at imaging: 77·5 years [SD 10·3]; 88 [43%] women). The 5-year ipsilateral stroke risk increased with the degree of stenosis; patients with 70-99% stenosis had a significantly greater 5-year ipsilateral stroke risk than did those with 50-69% stenosis (six [14·6%; 95% CI 3·5-25·7] of 53 patients vs none of 154; p<0·0001); and patients with 80-99% stenosis had a significantly greater 5-year ipsilateral stroke risk than did those with 50-79% stenosis (five [18·3%; 7·7-29·9] of 34 patients vs one [1·0%; 0·0-2·9] of 173; p<0·0001). Of the 56 studies identified in the systematic review (comprising 13 717 patients), 23 provided data on ipsilateral stroke risk fully stratified by degree of asymptomatic stenosis (in 8419 patients). Stroke risk was linearly associated with degree of ipsilateral stenosis (p<0·0001); there was a higher risk in patients with 70-99% stenosis than in those with 50-69% stenosis (386 of 3778 patients vs 181 of 3806 patients; odds ratio [OR] 2·1 [95% CI 1·7-2·5], p<0·0001; 15 cohort studies, three trials) and a higher risk in patients with 80-99% stenosis than in those with 50-79% stenosis (77 of 727 patients vs 167 of 3272 patients; OR 2·5 [1·8-3·5], p<0·0001; 11 cohort studies). Heterogeneity in stroke risk between studies for patients with severe versus moderate stenosis (phet<0·0001) was accounted for by highly discrepant results (pdiff<0·0001) in the randomised controlled trials of endarterectomy compared with cohort studies (trials: pooled OR 0·8 [95% CI 0·6-1·2], phet=0·89; cohorts: 2·9 [2·3-3·7], phet=0·54). INTERPRETATION: Contrary to the assumptions of current guidelines and the findings of subgroup analyses of previous randomised controlled trials, the stroke risk reported in cohort studies was highly dependent on the degree of asymptomatic carotid stenosis, suggesting that the benefit of endarterectomy might be underestimated in patients with severe stenosis. Conversely, the 5-year stroke risk was low for patients with moderate stenosis on contemporary medical treatment, calling into question any benefit from revascularisation. FUNDING: NIHR Oxford Biomedical Research Centre, Wellcome Trust, Wolfson Foundation, and the British Heart Foundation.


Assuntos
Estenose das Carótidas/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Estenose das Carótidas/complicações , Estenose das Carótidas/cirurgia , Estudos de Coortes , Endarterectomia das Carótidas , Feminino , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Ataque Isquêmico Transitório/epidemiologia , Ataque Isquêmico Transitório/etiologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Risco , Fumar/epidemiologia , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle
5.
J Stroke Cerebrovasc Dis ; 30(4): 105613, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33529924

RESUMO

INTRODUCTION: Experimental models have clearly demonstrated sex differences in the pathophysiology of stroke and prognosis, however clinical evidence remains elusive. In this study, we examined sex differences as a post hoc analysis of RELAXED (Recurrent Embolism Lessened by rivaroxaban, an anti-X agent, of Early Dosing for acute IS and TIA with atrial fibrillation) Study. METHODS: We stratified study participants by sex and compared baseline and clinical characteristics as well as clinical outcomes. The primary outcome measure was a good outcome defined as a modified Rankin Scale score of 0-2 at 90 days after stroke. Secondary outcomes were mortality at 90 days, intracranial hemorrhage within 90 days, and recurrence of stroke or transient ischemic attack within 90 days. We constructed a logistic regression model to estimate the adjusted odds ratio of female patients compared with male patients for the primary and secondary outcomes. RESULTS: Of 1303 patients, most were male (57.7%) with a mean age of 74.5 years. Female patients were older with a mean age of 80.6 ± 8.9 years and had significantly less frequent anticoagulation therapy before onset of stroke and more severe NIHSS scores. Good outcome was observed in 51.2% and 63.3% of the females and males (p < 0.0001). The adjusted odds ratio of a good outcome in females was 1.12 (95% confidence interval, 0.44-2.87) (p = 0.81). There were no sex differences in secondary outcomes. CONCLUSION: Adjusted regression analysis found no sex difference in the treatment outcomes at 90 days after stroke with non-valvular atrial fibrillation.


Assuntos
Fibrilação Atrial/tratamento farmacológico , Inibidores do Fator Xa/administração & dosagem , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde , Ataque Isquêmico Transitório/prevenção & controle , Rivaroxabana/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/mortalidade , Avaliação da Deficiência , /etiologia , Feminino , Humanos , Hemorragias Intracranianas/induzido quimicamente , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/etiologia , Ataque Isquêmico Transitório/mortalidade , Japão , Masculino , Pessoa de Meia-Idade , Recidiva , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores Sexuais , Fatores de Tempo , Resultado do Tratamento
6.
Am J Cardiol ; 144: 52-59, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33385355

RESUMO

Direct Oral Anticoagulants (DOACs) require dose adjustment based on specific patient characteristics, making them prone to incorrect dosing. The current study aimed to evaluate the prevalence of inappropriate DOAC dosing, its predictors, and corresponding outcomes in a single-center cohort of atrial fibrillation (AF) patients. We reviewed all patients with AF treated at Mayo Clinic with a DOAC (Apixaban, Rivaroxaban, or Dabigatran) between 2010 and 2017. Outcomes examined were ischemic stroke /transient ischemic attack (TIA)/embolism and bleeding. 8,576 patients (mean age 69.5 ± 11.9 years, 35.1 % female, CHA2DS2-VASc 3.0±1.8) received a DOAC (38.6% apixaban, 35.8% rivaroxaban, 25.6% dabigatran). DOAC dosing was inappropriate in 1,273 (14.8%) with 1071 (12.4%) receiving an inappropriately low dose, and 202(2.4%) an inappropriately high dose. Patients prescribed inappropriate doses were older (72.4 ± 11.7 vs 69.0 ± 11.8, p <0.0001), more likely to be female (43.1% vs 33.7%, p <0.0001), had a higher CHA2DS2-VASc score (3.4 ± 1.8 vs 2.9 ± 1.8, p <0.0001) and a greater Charlson co-morbidity index (3.5 ± 3.3 vs 2.9 ± 3.2, p<0.0001). Over 1.2 ±1.6 years (median 0.5 years) follow up; there was no significant difference in the incidence of stroke and/or TIA and/or embolism and bleeding between patients who were inappropriately dosed versus appropriately dosed. In conclusion, DOAC dosing was not in compliance with current recommendations in 15% of AF patients. Patients at higher risk of stroke and/or TIA based on older age, female gender, and higher CHA2DS2-VASc score were more likely to be underdosed, but there was no significant difference in outcomes including stroke/TIA/embolism and bleeding.


Assuntos
Fibrilação Atrial/tratamento farmacológico , Inibidores do Fator Xa/administração & dosagem , Erros de Medicação/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/complicações , Comorbidade , Dabigatrana/administração & dosagem , Cálculos da Dosagem de Medicamento , Embolia/etiologia , Embolia/prevenção & controle , Feminino , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Humanos , Ataque Isquêmico Transitório/etiologia , Ataque Isquêmico Transitório/prevenção & controle , Masculino , Pessoa de Meia-Idade , Pirazóis/administração & dosagem , Piridonas/administração & dosagem , Fatores de Risco , Rivaroxabana/administração & dosagem , Fatores Sexuais
7.
Vasc Endovascular Surg ; 55(4): 342-347, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33455523

RESUMO

OBJECTIVES: To describe the frequency, factors associated with, and significance of surgical dissection maneuvers of the distal internal carotid artery (ICA) during carotid endarterectomy (CEA). METHODS: In this retrospective analysis of prospectively collected information in patients undergoing CEA, we recorded information on demographics, risk factors and comorbidities, dissection maneuvers of the distal ICA, other operative variables and neurological outcome measures. RESULTS: During the period July 2008 and February 2020 inclusive, 218 consecutive patients (180 males, median age 69.5 years) underwent 240 CEAs. In 117 (48.8%) of them, CEA was performed for a symptomatic stenosis. Dissection maneuvers of the distal ICA were required in 77 cases (32.1%), including division and ligation of the sternocleidomastoid vessels in 66 cases (27.5%), mobilization of the XII cranial nerve in 69 cases (28.7%, with concomitant transection of the superior root of the ansa cervicalis in 11 cases, 4.6%) and division of the posterior belly of the digastric muscle in 8 cases (3.3%). Styloid osteotomy was not required in any case. Smoking was the single predictive factor associated with the use of an adjunctive dissection maneuver (odds ratio 2.23, p = 0.009). The use of a patch was more common in smokers (16% vs 7.1% in non-smokers, odds ratio 2.48, p = 0.05). Perioperative stroke and/or death rate was 0%, not allowing testing for associations with maneuver performance. Two patients (0.8%) developed a transient ischemic attack and 4 patients (1.7%) a cranial nerve injury (CNI), including 2 patients with recurrent laryngeal nerve palsy, diagnosed on routine laryngoscopy during planning of a contralateral CEA. There was no association between CNI and dissection of the distal ICA using an operative adjunct (p = 0.60). CONCLUSIONS: Several surgical maneuvers are often required to accomplish dissection of the distal ICA beyond the point of atherosclerotic disease. When dictated by operative findings, such maneuvers are deemed safe.


Assuntos
Artéria Carótida Interna/cirurgia , Estenose das Carótidas/cirurgia , Dissecação , Endarterectomia das Carótidas , Idoso , Artéria Carótida Interna/diagnóstico por imagem , Estenose das Carótidas/complicações , Estenose das Carótidas/diagnóstico por imagem , Dissecação/efeitos adversos , Endarterectomia das Carótidas/efeitos adversos , Feminino , Humanos , Ataque Isquêmico Transitório/etiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fumar/efeitos adversos , Resultado do Tratamento , Paralisia das Pregas Vocais/etiologia
8.
Am J Cardiol ; 145: 77-84, 2021 04 15.
Artigo em Inglês | MEDLINE | ID: mdl-33508268

RESUMO

Scarce data support the prescription of oral anticoagulation in patients with concomitant advanced chronic kidney disease (CKD) and atrial fibrillation, and left atrial appendage closure (LAAC) may provide a favorable risk-benefit ratio in this population. However, outcomes of LAAC in CKD patients are unknown. We aimed to investigate the impact of moderate-to-severe CKD on clinical outcomes following percutaneous LAAC. This was a multicenter study including 1094 patients who underwent LAAC. Moderate-to-severe CKD was defined as an eGFR<45 mL/min. Death, ischemic stroke, severe bleeding (≥BARC 3a) and serious adverse event (SAE; composite of death, stroke or severe bleeding) were recorded. A total of 300 patients (27.4%) had moderate-to-severe CKD. There were no differences between groups in periprocedural complications or device related thrombosis. At a median follow-up of 2 (1 to 3) years, patients with moderate-to-severe CKD did not present an increased risk of ischemic stroke (hazard ratio [HR]: 0.65; 95% confidence interval [CI]: 0.22 to 1.92; p = 0.435) but were at a higher risk of death (HR: 2.84; 95% CI: 2.22 to 3.64; p <0.001), severe bleeding (HR: 1.96; 95% CI: 1.36 to 2.81; p <0.001) and SAE (HR: 2.23; 95% CI: 1.80 to 2.77; p <0.001). By multivariable analysis, an eGFR<45 ml/min (HR: 1.92; 95% CI: 1.34 to 2.76; p <0.001) and previous bleeding (HR: 2.30; 95% CI: 1.27 to 4.17; p = 0.006) were associated with an increased risk of severe bleeding. In conclusion, patients with moderate-to-severe CKD who underwent LAAC had very high thrombotic and bleeding risks. Although the rates of device related thrombosis or ischemic stroke after-LAAC were not influenced by kidney dysfunction, patients with moderate-to-severe CKD remained at higher risk of severe bleeding events.


Assuntos
Apêndice Atrial/cirurgia , Fibrilação Atrial/cirurgia , Insuficiência Renal Crônica/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/uso terapêutico , Fibrilação Atrial/complicações , Fibrilação Atrial/epidemiologia , Procedimentos Cirúrgicos Cardíacos , Tamponamento Cardíaco/epidemiologia , Comorbidade , Embolia/etiologia , Embolia/prevenção & controle , Feminino , Taxa de Filtração Glomerular , Humanos , Ataque Isquêmico Transitório/etiologia , Ataque Isquêmico Transitório/prevenção & controle , Falência Renal Crônica/epidemiologia , Falência Renal Crônica/terapia , Masculino , Inibidores da Agregação de Plaquetas/uso terapêutico , Complicações Pós-Operatórias/epidemiologia , Hemorragia Pós-Operatória/epidemiologia , Diálise Renal , Índice de Gravidade de Doença , Acidente Vascular Cerebral/epidemiologia
11.
J Stroke Cerebrovasc Dis ; 29(11): 105207, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33066934

RESUMO

BACKGROUND: Cervical artery dissection is an important cause of stroke in the young. The etiology is still discussed controversial. The most obvious reason for a dissection of extracranial arteries is due to a trauma, eg. after car accidents or other high speed traumas such as high-velocity road traffic accidents. Besides these clear cases, chiropractic neck maneuvers represent potential reasons for vessel injuries. CASE PRESENTATION: We here report a rare case of secondary cervical artery dissection after so-called cupping therapy and a preventive treatment with a direct oral anticoagulant. CONCLUSIONS: Therapists using this technique should be aware of the potentially devastating side effects. The diagnosis of ICA dissection should be considered with any new onset of unknown neck pain or headache, specifically in combination with neurological deficits.


Assuntos
Dissecação da Artéria Carótida Interna/etiologia , Ventosaterapia/efeitos adversos , Ataque Isquêmico Transitório/etiologia , Administração Oral , Anticoagulantes/administração & dosagem , Dissecação da Artéria Carótida Interna/diagnóstico por imagem , Dissecação da Artéria Carótida Interna/tratamento farmacológico , Substituição de Medicamentos , Humanos , Ataque Isquêmico Transitório/diagnóstico por imagem , Ataque Isquêmico Transitório/tratamento farmacológico , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/administração & dosagem , Pressão , Recidiva , Resultado do Tratamento
12.
J Stroke Cerebrovasc Dis ; 29(10): 105155, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32912494

RESUMO

BACKGROUND: There is not a widely accepted optimal rate of stent opening in patients underwent carotid artery stenting. In this study we evaluated the effect of carotid stent opening rate (CSOR) without performing post-dilation on in-hospital and long-term outcomes. METHODS: A total of 825 patient patients underwent carotid artery stenting without post-dilation enrolled to the study. The patients divided into two groups according to their final CSOR (50% ≤ Post-stent deployment (SD) <80% and 80% ≤ Post-SD ≤ 100%). In-hospital and 3-year outcomes were compared between the groups. RESULTS: During hospitalization, the rate of ipsilateral stroke, major stroke and transient ischemic attacks were similar between the groups (respectively; 6.2% vs. 4.1, P = 0.190; 1.5% vs. 1.8, P = 0.811; 1.5% vs. 1.9%, P = 0.683). The 3-year Kaplan-Meier overall survival rates for the first and second groups were 87.6% and 84.4%, respectively (log rank test P = 0.426). The 3-year Kaplan-Meier overall cumulative ipsilateral stroke rates for the first and second groups were 88.0% and 88.6%, respectively (log rank test P = 0.409) CONCLUSION: Our study demonstrated that a CSOR higher than 50% without performing a post-dilation might be an effective therapeutic approach since there was not a significant difference regarding outcomes between the patients with a 50% ≤ Post-SD <80% and 80% ≤ Post-SD ≤ 100%. The need for post-stent balloon dilation might have been eliminated due to subsequent stent self-expansion.


Assuntos
Angioplastia com Balão/instrumentação , Estenose das Carótidas/terapia , Stents , Idoso , Angioplastia com Balão/efeitos adversos , Angioplastia com Balão/mortalidade , Estenose das Carótidas/complicações , Estenose das Carótidas/mortalidade , Feminino , Humanos , Ataque Isquêmico Transitório/etiologia , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Fatores de Tempo , Resultado do Tratamento
13.
BMC Neurol ; 20(1): 352, 2020 Sep 19.
Artigo em Inglês | MEDLINE | ID: mdl-32950057

RESUMO

BACKGROUND: Moyamoya-like vasculopathy (MMV) and myosin heavy chain 9-related platelet disorders (MYH9-RPDs) or macrothrombocitopenias are rare syndromes. Their association is even more infrequent. CASE PRESENTATION: A 29-year-old female with history of MYH9-RPD, presented to our department for episodes suggesting transient ischemic attacks. Based on the imaging studies that revealed multiple ischemic lesions and stenoses of both distal internal carotid arteries and the arteries of the circle of Willis, the diagnosis of MMV was established. The treatment with Verapamil was initiated, leading to symptom remission. Two months later, the patient presented one episode of dysarthria, followed by involuntary movements of the right upper limb, few days later. Long-term electroencephalogram monitoring depicted epileptiform abnormalities. Resolution of symptoms was obtained after increasing the dose of Verapamil, and initiating Levetiracetam. CONCLUSIONS: This is an interesting case of a patient with two rare pathologies, who presented with cerebral ischemic strokes. To our knowledge there are few cases described in the literature presenting with cerebral hemorrhagic events but none of them with multiple cerebral ischemic lesions. As these cases are very rare, it is important to gather evidence regarding the best approach and treatment strategy.


Assuntos
Ataque Isquêmico Transitório/etiologia , Doença de Moyamoya/complicações , Cadeias Pesadas de Miosina/genética , Trombocitopenia/complicações , Trombocitopenia/genética , Adulto , Feminino , Humanos
14.
Cochrane Database Syst Rev ; 9: CD001081, 2020 09 12.
Artigo em Inglês | MEDLINE | ID: mdl-32918282

RESUMO

BACKGROUND: Stroke is the third leading cause of death and the most common cause of long-term disability. Severe narrowing (stenosis) of the carotid artery is an important cause of stroke. Surgical treatment (carotid endarterectomy) may reduce the risk of stroke, but carries a risk of operative complications. This is an update of a Cochrane Review, originally published in 1999, and most recently updated in 2017. OBJECTIVES: To determine the balance of benefit versus risk of endarterectomy plus best medical management compared with best medical management alone, in people with a recent symptomatic carotid stenosis (i.e. transient ischaemic attack (TIA) or non-disabling stroke). SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, Web of Science Core Collection, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) portal to October 2019. We also reviewed the reference lists of all relevant studies and abstract books from research proceedings. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing carotid artery surgery plus best medical treatment with best medical treatment alone.  DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies, assessed risk of bias, and extracted the data. We assessed the results and the quality of the evidence of the primary and secondary outcomes by the GRADE method, which classifies the quality of evidence as high, moderate, low, or very low. MAIN RESULTS: We included three trials involving 6343 participants. The trials differed in the methods of measuring carotid stenosis and in the definition of stroke. Using the primary electronic data files, we pooled and analysed individual patient data on 6092 participants (35,000 patient-years of follow-up), after reassessing the carotid angiograms and outcomes from all three trials, and redefining outcome events where necessary, to achieve comparability. Surgery increased the five-year risk of any stroke or operative death in participants with less than 30% stenosis (risk ratio (RR) 1.25, 95% confidence interval (CI) 0.99 to 1.56; 2 studies, 1746 participants; high-quality evidence). Surgery decreased the five-year risk of any stroke or operative death in participants with 30% to 49% stenosis (RR 0.97, 95% CI 0.79 to 1.19; 2 studies, 1429 participants; high-quality evidence), was of benefit in participants with 50% to 69% stenosis (RR 0.77, 95% CI 0.63 to 0.94; 3 studies, 1549 participants; moderate-quality evidence), and was highly beneficial in participants with 70% to 99% stenosis without near-occlusion (RR 0.53, 95% CI 0.42 to 0.67; 3 studies, 1095 participants; moderate-quality evidence). However, surgery decreased the five-year risk of any stroke or operative death in participants with near-occlusions (RR 0.95, 95% CI 0.59 to 1.53; 2 studies, 271 participants; moderate-quality evidence). AUTHORS' CONCLUSIONS: Carotid endarterectomy reduced the risk of recurrent stroke for people with significant stenosis. Endarterectomy might be of some benefit for participants with 50% to 69% symptomatic stenosis (moderate-quality evidence) and highly beneficial for those with 70% to 99% stenosis (moderate-quality evidence).


Assuntos
Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas , Complicações Pós-Operatórias/prevenção & controle , Acidente Vascular Cerebral/prevenção & controle , Adulto , Fatores Etários , Idoso , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/patologia , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/mortalidade , Endarterectomia das Carótidas/normas , Feminino , Humanos , Ataque Isquêmico Transitório/etiologia , Masculino , Complicações Pós-Operatórias/etiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Risco , Fatores Sexuais , Acidente Vascular Cerebral/etiologia , Fatores de Tempo
15.
J Stroke Cerebrovasc Dis ; 29(10): 105048, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32912514

RESUMO

OBJECTIVE: Standards for reporting and analyzing adherence to medical therapy have recently improved due to international consensus efforts. If applied to clinical trial research in patients with stroke, these improvements have the potential to identify when in the sequence of trial operations participants are at risk for non-adherence and opportunities to safeguard adherence. METHODS: We analyzed three phases of adherence according to the European Society for Patient Adherence, COMpliance, and Persistence (ESPACOMP) Medication Adherence Reporting Guideline (EMERGE) taxonomy in the Insulin Resistance Intervention after Stroke (IRIS) trial: initiation (did patient start drug), implementation (did patient take a drug holiday, defined as temporary cessation lasting ≥14 days), and persistence (did patient prematurely and permanently discontinue drug). IRIS was a randomized, placebo controlled, double-blind trial testing pioglitazone to prevent stroke or myocardial infarction in patients with a recent ischemic stroke or transient ischemic attack. Adherence was classified by self-report. Researchers used coaching algorithms to seek adherence recovery if participants went off drug. RESULTS: During 2005-2013, 3876 participants were enrolled from 179 sites in seven countries and followed for a mean of 4.8 years. Less than 1% of participants in each group did not initiate study drug. 20% of patients assigned to pioglitazone and 17% assigned to placebo took at least one drug holiday. 36% and 30%, respectively, discontinued the study drug prematurely with or without a prior holiday. The risk for stopping the study drug (temporarily or permanently) in the first year after randomization was twice the risk in each of the subsequent four years. This was true both for patients assigned to active therapy and placebo. More participants assigned to pioglitazone, compared to placebo, took a drug holiday or permanently stopped study drug, but the difference in rates of discontinuation was only evident in year one. In years two through five, rates of discontinuation were similar in the two treatment groups. The difference in rates during year one was the result of adverse effects related to the active study drug, pioglitazone. During the remainder of the trial, the attribution of discontinuations to adverse effects potentially related to pioglitazone was reduced but still higher in those assigned to active drug. Other reasons for discontinuation were similar between treatment groups and were largely unrelated to pharmacodynamic effects of the study drug. Rates of discontinuation varied widely among research sites. CONCLUSION: Patients in a drug trial for stroke prevention are at greatest risk for premature drug discontinuation early after randomization. Reasons for discontinuation change over time. Variable discontinuation rates among sites suggests that adherence can be improved by using best practices from high-performing sites.


Assuntos
Hipoglicemiantes/administração & dosagem , Resistência à Insulina , Ataque Isquêmico Transitório/prevenção & controle , Adesão à Medicação , Infarto do Miocárdio/prevenção & controle , Pioglitazona/administração & dosagem , Prevenção Secundária , Acidente Vascular Cerebral/prevenção & controle , Método Duplo-Cego , Esquema de Medicação , Feminino , Humanos , Hipoglicemiantes/efeitos adversos , Ataque Isquêmico Transitório/etiologia , Ataque Isquêmico Transitório/fisiopatologia , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/fisiopatologia , Pioglitazona/efeitos adversos , Recidiva , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
16.
J Stroke Cerebrovasc Dis ; 29(10): 105051, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32912558

RESUMO

RATIONALE: Intracranial atherosclerotic disease (ICAD) is the most common cause of ischemic stroke with the highest rate of recurrence, despite aggressive medical management. Diverse mechanisms may be responsible for ICAD-related cerebral ischemia, with potential therapeutic implications. Here we present the rationale, design and methods of the Mechanisms of Early Recurrence in Intracranial Atherosclerotic Disease (MyRIAD) study. The aim of MyRIAD is to determine the mechanisms of stroke in ICAD through physiologic imaging biomarkers that evaluate impaired antegrade flow, poor distal perfusion, abnormal vasoreactivity, artery to artery embolism, and their interaction. METHODS AND DESIGN: This is a prospective observational study of patients with recently symptomatic (<21 days) ICAD with 50-99% stenosis treated medically and monitored for up to 1 year. An estimated 110 participants are recruited at 10 sites to identify the association between the presence of each mechanism of ischemia and recurrent stroke. The primary outcome is ischemic stroke in the territory of the symptomatic artery. Secondary outcomes include new cerebral infarction on MRI at 6-8 weeks and recurrent TIA in the territory of the symptomatic artery. DISCUSSION: MyRIAD is positioned to define the role of specific mechanisms of recurrent ischemia in patients with symptomatic ICAD. This knowledge will allow the development and implementation of effective and specific treatments for this condition.


Assuntos
Infarto Encefálico/etiologia , Circulação Cerebrovascular , Arteriosclerose Intracraniana/diagnóstico por imagem , Ataque Isquêmico Transitório/etiologia , Angiografia por Ressonância Magnética , Projetos de Pesquisa , Ultrassonografia Doppler Transcraniana , Adulto , Infarto Encefálico/diagnóstico por imagem , Infarto Encefálico/fisiopatologia , Infarto Encefálico/terapia , Feminino , Humanos , Arteriosclerose Intracraniana/complicações , Arteriosclerose Intracraniana/fisiopatologia , Arteriosclerose Intracraniana/terapia , Ataque Isquêmico Transitório/diagnóstico por imagem , Ataque Isquêmico Transitório/fisiopatologia , Ataque Isquêmico Transitório/terapia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Recidiva , Fatores de Risco , Fatores de Tempo
17.
JAMA ; 324(9): 871-878, 2020 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-32870297

RESUMO

Importance: Outcomes of postoperative atrial fibrillation (AF) after noncardiac surgery are not well defined. Objective: To determine the association of new-onset postoperative AF vs no AF after noncardiac surgery with risk of nonfatal and fatal outcomes. Design, Setting, and Participants: Retrospective cohort study in Olmsted County, Minnesota, involving 550 patients who had their first-ever documented AF within 30 days after undergoing a noncardiac surgery (postoperative AF) between 2000 and 2013. Of these patients, 452 were matched 1:1 on age, sex, year of surgery, and type of surgery to patients with noncardiac surgery who were not diagnosed with AF within 30 days following the surgery (no AF). The last date of follow-up was December 31, 2018. Exposures: Postoperative AF vs no AF after noncardiac surgery. Main Outcomes and Measures: The primary outcome was ischemic stroke or transient ischemic attack (TIA). Secondary outcomes included subsequent documented AF, all-cause mortality, and cardiovascular mortality. Results: The median age of the 452 matched patients was 75 years (IQR, 67-82 years) and 51.8% of patients were men. Patients with postoperative AF had significantly higher CHA2DS2-VASc scores than those in the no AF group (median, 4 [IQR, 2-5] vs 3 [IQR, 2-5]; P < .001). Over a median follow-up of 5.4 years (IQR, 1.4-9.2 years), there were 71 ischemic strokes or TIAs, 266 subsequent documented AF episodes, and 571 deaths, of which 172 were cardiovascular related. Patients with postoperative AF exhibited a statistically significantly higher risk of ischemic stroke or TIA (incidence rate, 18.9 vs 10.0 per 1000 person-years; absolute risk difference [RD] at 5 years, 4.7%; 95% CI, 1.0%-8.4%; HR, 2.69; 95% CI, 1.35-5.37) compared with those with no AF. Patients with postoperative AF had statistically significantly higher risks of subsequent documented AF (incidence rate 136.4 vs 21.6 per 1000 person-years; absolute RD at 5 years, 39.3%; 95% CI, 33.6%-45.0%; HR, 7.94; 95% CI, 4.85-12.98), and all-cause death (incidence rate, 133.2 vs 86.8 per 1000 person-years; absolute RD at 5 years, 9.4%; 95% CI, 4.9%-13.7%; HR, 1.66; 95% CI, 1.32-2.09). No significant difference in the risk of cardiovascular death was observed for patients with and without postoperative AF (incidence rate, 42.5 vs 25.0 per 1000 person-years; absolute RD at 5 years, 6.2%; 95% CI, 2.2%-10.4%; HR, 1.51; 95% CI, 0.97-2.34). Conclusions and Relevance: Among patients undergoing noncardiac surgery, new-onset postoperative AF compared with no AF was associated with a significant increased risk of stroke or TIA. However, the implications of these findings for the management of postoperative AF, such as the need for anticoagulation therapy, require investigation in randomized trials.


Assuntos
Fibrilação Atrial/complicações , Ataque Isquêmico Transitório/etiologia , Complicações Pós-Operatórias/etiologia , Acidente Vascular Cerebral/etiologia , Procedimentos Cirúrgicos Operatórios , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/epidemiologia , Feminino , Seguimentos , Humanos , Incidência , Ataque Isquêmico Transitório/epidemiologia , Masculino , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Risco , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia
18.
J Med Vasc ; 45(5): 260-267, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32862983

RESUMO

OBJECTIVE: Carotid endarterectomy has traditionally been the strategy for the surgical management of carotid stenosis. Alongside the usual techniques, this study presents another technique: endarterectomy with systematized resection-anastomosis. MATERIAL AND METHODS: A retrospective study from January 2006 to December 2018, included all patients managed for carotid stenosis at Meaux hospital with the "endarterectomy with systematized resection-anastomosis" technique. The perioperative death and stroke rate were evaluated according to the judgment criterion "homolateral ischemic stroke and any stroke or perioperative death". Statistical analysis of the data was performed using SPSS software. RESULTS: For 415 carotids operated, we identified 240 managed with this technique. The average age was 71.7±9.6 years, 70% men and 30% women. The main cardiovascular risk factor was hypertension (76.7%), 24.2% of patients had an ischemic heart disease history, 43.7% homolateral ischemic stroke and 29% transient ischemic attack. Bilateral lesions were diagnosed in 6.2% of patients and 7.5% had contralateral occlusion. Carotid stenosis was symptomatic in 52.9% of patients. The average stenosis rate observed was 82.9±8.1% on computed tomography angiogram and 83.7±7.7% on magnetic resonance angiogram. The shunt was used in 45.4% of procedures. The average length of stay was 5.9±2.3 days. All patients had satisfactory results in terms of patency and anatomical appearance on the 1st check. In the post-operative period during the first month, complications occurred in 12.5% of patients (1.6% acute coronary syndrome, 0.8% neurological event, 0.8% death, 0.4% infection, 12.1% hematoma, 1.6% recovery for bleeding). The overall perioperative death and stroke rate was 2.6%. Myocardial infarction and sepsis were the causes of death for the 2 patients in the peri operative period. The mean duration of follow-up was 21.2 months, without any restenosis or occurrence of neurological complications. One patient died beyond the 1st month of follow-up without established cause, and the overall mortality rate was 1.3%. CONCLUSION: Thromboendarterectomy with "systematized" anastomosis resection represents an angioplasty method for carotid stenosis surgical management under visual control.


Assuntos
Artérias Carótidas/cirurgia , Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas , Idoso , Idoso de 80 Anos ou mais , Anastomose Cirúrgica , Isquemia Encefálica/etiologia , Artérias Carótidas/diagnóstico por imagem , Estenose das Carótidas/complicações , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/mortalidade , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/mortalidade , Feminino , Humanos , Ataque Isquêmico Transitório/etiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Fatores de Tempo , Resultado do Tratamento
19.
J Stroke Cerebrovasc Dis ; 29(9): 105062, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32807467

RESUMO

BACKGROUND AND PURPOSE: To study the feasibility and clinical utility of head-neck joint high-resolution vessel wall imaging (HNJ-VWI) in the assessment of ischemic stroke. METHODS: We reviewed our institutional HNJ-VWI database. Patients with transient ischemic attack (TIA) or ischemic stroke were included. Abnormal findings of intracranial and/or extracranial artery were assessed on three-dimensional time-of-flight magnetic resonance angiography (3D TOF MRA) and HNJ-VWI modified from high-resolution 3D T1 sequence and classified into three groups including intracranial, extracranial and coexisting based on the locations. Etiologies of stroke were recorded according to Trial of Org 10172 in Acute Stroke Treatment criteria. RESULTS: One hundred and ten consecutive patients were studied. 3D TOF MRA displayed 71.8% (79/110, based on patients) abnormal arteries (stenosis or occlusion) , while HNJ-VWI displayed 96.3% (106/110) abnormal arteries (plaque,wall thickness and occlusion) including four isolated extracranial lesions and ten coexisting lesions. The etiologies of TIA/ischemic stroke included large artery atherosclerosis (80 cases), cerebral small vessel disease (6 cases), cardiogenic (2 cases), dissection (6 cases), vasculitis (4 cases), moyamoya disease (6 cases), others (2 cases) and undetermined (4 cases). For patients with atherosclerosis stroke, re-infarctions were more common in coexisting group than intracranial group (extracranial vs. intracranial vs coexisting: 0% vs. 9.1% vs. 43.7%, p = 0.001). CONCLUSIONS: HNJ-VWI is a feasible and valuable technique in assessment of ischemic stroke by detecting extracranial and intracranial artery abnormalities with one-step scan.


Assuntos
Infarto Encefálico/diagnóstico por imagem , Angiografia Cerebral/métodos , Artérias Cerebrais/diagnóstico por imagem , Ataque Isquêmico Transitório/diagnóstico por imagem , Articulações/irrigação sanguínea , Angiografia por Ressonância Magnética , Adulto , Infarto Encefálico/etiologia , Estudos de Viabilidade , Feminino , Humanos , Ataque Isquêmico Transitório/etiologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Fatores de Risco
20.
Stroke ; 51(9): 2786-2794, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32811384

RESUMO

BACKGROUND AND PURPOSE: Chronic kidney disease (CKD) is strongly associated with stroke risk, but the mechanisms underlying this association are unclear and might be informed by subtype-specific analyses. However, few studies have reported stroke subtypes in CKD according to established classification systems, such as the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) criteria. We, therefore, aimed to determine which transient ischemic attack and ischemic stroke subtypes using the TOAST classification occur most frequently in patients with CKD. METHODS: In a population-based study of all transient ischemic attack and stroke (OXVASC [Oxford Vascular Study]; 2002-2017), all ischemic events were classified by TOAST subtypes (cardioembolism, large artery disease, small vessel disease, undetermined, multiple, other etiology, or incompletely investigated). Logistic regression was used to determine the relationship between CKD (defined as an estimated glomerular filtration rate <60 mL/min per 1.73 m2) and transient ischemic attack/stroke subtypes adjusted for age, sex, and hypertension and then stratified by age and estimated glomerular filtration rate category. RESULTS: Among 3178 patients with transient ischemic attack (n=1167), ischemic stroke (n=1802), and intracerebral hemorrhage (n=209), 1267 (40%) had CKD. Although there was a greater prevalence of cardioembolic events (31.8% versus 21.2%; P<0.001) in patients with CKD, this association was lost after adjustment for age, sex, and hypertension (adjusted odds ratio=1.20 [95% CI, 0.99-1.45]; P=0.07). Similarly, although patients with CKD had a lower prevalence of small vessel disease (8.8% versus 13.6%; P<0.001), undetermined (26.1% versus 39.4%; P<0.001), and other etiology (1.0% versus 3.6%; P<0.001) subtypes, these associations were also lost after adjustment (adjusted odds ratio=0.86 [0.65-1.13]; P=0.27 and 0.73 [0.36-1.43]; P=0.37 for small vessel disease and other defined etiology, respectively) for all but undetermined (adjusted odds ratio=0.81 [0.67-0.98]; P=0.03). CONCLUSIONS: There were no independent positive associations between CKD and specific TOAST subtypes, which suggest that renal-specific risk factors are unlikely to play an important role in the etiology of particular subtypes. Future studies of stroke and CKD should report subtype-specific analyses to gain further insights into potential mechanisms.


Assuntos
Isquemia Encefálica/etiologia , Ataque Isquêmico Transitório/etiologia , Insuficiência Renal Crônica/complicações , Acidente Vascular Cerebral/etiologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/classificação , Feminino , Taxa de Filtração Glomerular , Humanos , Hipertensão/complicações , Hipertensão/epidemiologia , Ataque Isquêmico Transitório/classificação , Masculino , Pessoa de Meia-Idade , Prevalência , Fatores de Risco , Fatores Sexuais , Acidente Vascular Cerebral/classificação
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