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1.
Medicine (Baltimore) ; 99(40): e22465, 2020 Oct 02.
Artigo em Inglês | MEDLINE | ID: mdl-33019438

RESUMO

The present study aimed to investigate the predictive value of free fatty acid (FFA) in embolic stroke of undetermined source (ESUS) according to the presence of potential embolic sources (PES) after extensive etiologic evaluation.This was a retrospective observational study based on a single-center registry from January 2011 to July 2017. Stroke subtypes were determined through laboratory findings, brain, and angiographic imaging, carotid ultrasonography, transthoracic echocardiography, and 24-hour Holter monitoring. If ESUS was suspected, transesophageal echocardiography was additionally performed. Patients were classified into ESUS with PES and ESUS without PES. PES included mitral annular calcification, mitral valve prolapse, patent foramen ovale, atrial septal aneurysm, spontaneous echo contrast, ventricular aneurysm, and high-risk plaques of aortic arch, or carotid bulb. We compared clinical and laboratory findings between the two groups.Of a total of 110 ESUS patients, 61 patients (55.5%) had no PES. Patients with ESUS without PES had higher levels of serum FFA, systolic blood pressure, diastolic blood pressure (DBP), and left atrial (LA) enlargement compared with those of ESUS with PES. Multivariable analysis demonstrated that the FFA level, DBP, and LA volume index were associated with ESUS without PES [odds ratio (OR) 1.038, 95% confidence interval (CI) 1.019-1.058 for FFA/10 µEq/L, OR 1.414, 95% CI 1.037-1.928 for DBP/10 mm Hg, and OR 1.073, 95% CI 1.009-1.141 for LA volume index].Higher levels of FFA, DBP, and LA volume index are associated with ESUS without PES, highlighting the need to identify the role of these markers in ESUS through further large-scale, multi-center and prospective studies.


Assuntos
Ácidos Graxos não Esterificados/sangue , Embolia Intracraniana/sangue , Acidente Vascular Cerebral/sangue , Idoso , Biomarcadores/sangue , Feminino , Humanos , Embolia Intracraniana/complicações , Embolia Intracraniana/diagnóstico , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Sistema de Registros , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia
2.
Stroke ; 51(9): e203-e210, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32781943

RESUMO

BACKGROUND AND PURPOSE: One-fifth of ischemic strokes are embolic strokes of undetermined source (ESUS). Their theoretical causes can be classified as cardioembolic versus noncardioembolic. This distinction has important implications, but the categories' proportions are unknown. METHODS: Using data from the Cornell Acute Stroke Academic Registry, we trained a machine-learning algorithm to distinguish cardioembolic versus non-cardioembolic strokes, then applied the algorithm to ESUS cases to determine the predicted proportion with an occult cardioembolic source. A panel of neurologists adjudicated stroke etiologies using standard criteria. We trained a machine learning classifier using data on demographics, comorbidities, vitals, laboratory results, and echocardiograms. An ensemble predictive method including L1 regularization, gradient-boosted decision tree ensemble (XGBoost), random forests, and multivariate adaptive splines was used. Random search and cross-validation were used to tune hyperparameters. Model performance was assessed using cross-validation among cases of known etiology. We applied the final algorithm to an independent set of ESUS cases to determine the predicted mechanism (cardioembolic or not). To assess our classifier's validity, we correlated the predicted probability of a cardioembolic source with the eventual post-ESUS diagnosis of atrial fibrillation. RESULTS: Among 1083 strokes with known etiologies, our classifier distinguished cardioembolic versus noncardioembolic cases with excellent accuracy (area under the curve, 0.85). Applied to 580 ESUS cases, the classifier predicted that 44% (95% credibility interval, 39%-49%) resulted from cardiac embolism. Individual ESUS patients' predicted likelihood of cardiac embolism was associated with eventual atrial fibrillation detection (OR per 10% increase, 1.27 [95% CI, 1.03-1.57]; c-statistic, 0.68 [95% CI, 0.58-0.78]). ESUS patients with high predicted probability of cardiac embolism were older and had more coronary and peripheral vascular disease, lower ejection fractions, larger left atria, lower blood pressures, and higher creatinine levels. CONCLUSIONS: A machine learning estimator that distinguished known cardioembolic versus noncardioembolic strokes indirectly estimated that 44% of ESUS cases were cardioembolic.


Assuntos
Embolia Intracraniana/patologia , Aprendizado de Máquina , Acidente Vascular Cerebral/patologia , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Fibrilação Atrial/complicações , Árvores de Decisões , Eletrocardiografia , Feminino , Humanos , Processamento de Imagem Assistida por Computador , Embolia Intracraniana/complicações , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Curva ROC , Sistema de Registros , Reprodutibilidade dos Testes , Acidente Vascular Cerebral/etiologia
3.
Stroke ; 51(7): 2139-2147, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32517582

RESUMO

BACKGROUND AND PURPOSE: Risks, sites, and predictors of major bleeding during antithrombotic therapies have not been well defined for patients with recent embolic stroke of undetermined source. METHODS: Exploratory analysis of major bleeds defined by International Society of Thrombosis and Hemostasis criteria occurring among 7213 participants in international NAVIGATE (New Approach Rivaroxaban Inhibition of Factor Xa in a Global Trial) embolic stroke of undetermined source randomized trial comparing rivaroxaban 15 mg daily with aspirin 100 mg daily. RESULTS: During a median follow-up of 11 months, 85 major bleeds occurred. The most frequent site was gastrointestinal (38%), followed by intracranial (29%). Assignment to rivaroxaban (hazard ratio [HR], 2.7 [95% CI, 1.7-4.3]), East Asia region (HR, 2.5 [95% CI, 1.6-3.9]), systolic blood pressure ≥160 mm Hg (HR, 2.2 [95% CI, 1.2-3.8]), and reduced estimated glomerular filtration rate (HR, 1.2 per 10 mL/min per 1.73 m2 decrease, [95% CI, 1.0-1.3]) were independently associated with presence of major bleeds. Five (6%) were fatal. Among 15 patients with intracerebral hemorrhage, 2 (13%) were fatal. There was no evidence of an early high-risk period following initiation of rivaroxaban. The annualized rate of intracerebral hemorrhage was 6-fold higher among East Asian participants (0.67%) versus all other regions (0.11%; HR, 6.3 [95% CI, 2.2-18.0]). Distribution of bleeding sites was similar for rivaroxaban and aspirin. CONCLUSIONS: Among embolic stroke of undetermined source patients participating in an international randomized trial, independent predictors of major bleeding were assignment to rivaroxaban, East Asia region, increased systolic blood pressure, and impaired renal function. East Asia as a region was strongly associated with risk of intracerebral hemorrhage. Estimated glomerular filtration rate should be a consideration for stratifying bleeding risk. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02313909.


Assuntos
Hemorragia Cerebral/induzido quimicamente , Inibidores do Fator Xa/efeitos adversos , Rivaroxabana/efeitos adversos , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Adulto , Idoso , Grupo com Ancestrais do Continente Asiático , Método Duplo-Cego , Extremo Oriente , Feminino , Taxa de Filtração Glomerular , Hemorragia/induzido quimicamente , Humanos , Embolia Intracraniana/complicações , Masculino , Pessoa de Meia-Idade , Fatores de Risco
4.
BMJ Case Rep ; 13(1)2020 Jan 22.
Artigo em Inglês | MEDLINE | ID: mdl-31974261

RESUMO

Non-compaction of ventricular myocardium is a rare cardiomyopathy involving an early arrest of normal compaction of myocardium during fetal ontogenesis. Autosomal dominant polycystic kidney disease (ADPKD) is a hereditary nephropathy characterised by multiple renal cysts replacing the renal parenchyma and extrarenal manifestations. Here, we report a case of 65-year-old man, chronic smoker, presented with sudden onset right brachial monoparesis, exertional dyspnoea, orthopnoea, bipedal swelling and diagnosed as a case of ADPKD with left ventricular non-compaction cardiomyopathy with acute left ventricular failure and cardiogenic cerebral embolism (no evidence of atrial fibrillation); based on characteristic appearance on two-dimensional echocardiography and cardiac magnetic resonance. The patient was managed with guideline-directed pharmacotherapy for heart failure and anticoagulation as a secondary stroke prevention measure. Through this case report, we try to discuss the association between two rare entities and individualisation of treatment options available as a case-based approach, as no standard treatment guidelines are available.


Assuntos
Insuficiência Cardíaca/complicações , Embolia Intracraniana/complicações , Miocárdio Ventricular não Compactado Isolado/complicações , Rim Policístico Autossômico Dominante/complicações , Idoso , Humanos , Masculino
5.
Medicine (Baltimore) ; 99(2): e18694, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31914070

RESUMO

RATIONALE: Some patients with pulmonary arteriovenous malformation (PAVM) present with hypoxemia and life-threatening complications, including stroke and cerebral abscess. Catheter embolization is currently the preferred treatment for PAVM. However, previous studies have revealed that the incidence of PAVM recanalization is approximately 10% 5 to 7 years after embolization. In contrast, there are no studies where recanalization has occurred over 10 years after embolization. PATIENT CONCERNS: Herein, we report 2 cases diagnosed with cerebral embolism due to PAVM recanalization 13 years and 30 years after catheter treatment, in case I and II, respectively. DIAGNOSES: Both cases were diagnosed with PAVM recanalization on chest computed tomography (CT) examination performed after cerebral embolism development. Furthermore, pulmonary artery angiography revealed blood flow from the pulmonary artery to the vein in the PAVM, confirming PAVM recanalization. INTERVENTIONS: Coil re-embolization was performed for the all recanalized PAVM. OUTCOMES: All the target lesions were successfully re-embolized in both cases. However, in case I, the second recanalization of embolized PAVM was confirmed 1 year after coil re-embolization. Consequently, the third embolization was performed in case I. In contrast to case I, the patient in case II was followed up without recanalization for 2 years after embolization. LESSONS: We described the first 2 cases diagnosed with PAVM recanalization >10 years after the first catheter embolization. These cases suggest that patients with PAVMs should undergo life-long follow-up after catheter embolization.


Assuntos
Fístula Arteriovenosa/complicações , Fístula Arteriovenosa/terapia , Embolização Terapêutica/métodos , Embolia Intracraniana/complicações , Embolia Intracraniana/terapia , Artéria Pulmonar/anormalidades , Veias Pulmonares/anormalidades , Idoso , Feminino , Humanos
6.
Intern Med ; 59(2): 211-214, 2020 Jan 15.
Artigo em Inglês | MEDLINE | ID: mdl-31484914

RESUMO

A 73-year-old man was transferred to our hospital with dyspnea and left hemiplegia. The diagnosis of pulmonary embolism, entrapped thrombus in patent foramen ovale (PFO), and internal carotid artery occlusion was made by imaging studies. We decided to perform endovascular treatment without the administration of tissue plasminogen activator (tPA) for cerebral embolism because of concern about further embolism caused by fragmented thrombi. After endovascular treatment, he successfully underwent surgical embolectomy for entrapped thrombus in PFO. Endovascular treatment without tPA administration and subsequent surgical embolectomy seems to be a viable treatment strategy for patients with occlusion of the large cerebral artery accompanied by entrapped thrombus in PFO.


Assuntos
Forame Oval Patente/complicações , Embolia Intracraniana/complicações , Embolia Pulmonar/complicações , Trombose/complicações , Idoso , Embolectomia , Feminino , Hemiplegia , Humanos , Masculino , Embolia Pulmonar/cirurgia , Trombose/cirurgia
7.
JAMA Neurol ; 77(1): 43-48, 2020 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-31524941

RESUMO

Importance: The COMPASS (Cardiovascular Outcomes for People Using Anticoagulation Strategies) randomized clinical trial was stopped early owing to the efficacy of low-dose rivaroxaban plus aspirin in preventing major cardiovascular events. The main reason for early trial termination was the effect of combination therapy on reducing ischemic strokes. Objective: To analyze the association between low-dose rivaroxaban with or without aspirin and different ischemic stroke subtypes. Design, Setting, and Participants: This is a secondary analysis of a multicenter, double-blind, randomized, placebo-controlled study that was performed in 33 countries from March 12, 2013, to May 10, 2016. Patients with stable atherosclerotic vascular disease were eligible, and a total of 27 395 participants were randomized and followed up to February 6, 2017. All first ischemic strokes and uncertain strokes that occurred by this date were adjudicated using TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria. The analysis of ischemic stroke subtypes was evaluated using an intention-to-treat principle. Statistical analysis was performed from March 12, 2013, to February 6, 2017. Interventions: Participants received rivaroxaban (2.5 mg twice a day) plus aspirin (100 mg once a day), rivaroxaban (5 mg twice a day), or aspirin (100 mg once a day). Main Outcomes and Measures: Risk of ischemic stroke subtypes during follow-up. Results: A total of 291 patients (66 women; mean [SD] age, 69.4 [8.5] years; 43 [14.8%] had a previous nonlacunar stroke) experienced an ischemic stroke. During the study, 49 patients (16.8%) received a diagnosis of atrial fibrillation. Applying TOAST criteria, 59 strokes (20.3%) were cardioembolic, 54 strokes (18.6%) were secondary to greater than 50% stenosis of the ipsilateral internal carotid artery, 42 strokes (14.4%) had a negative evaluation that met criteria for embolic stroke of undetermined source, and 21 strokes (7.2%) were secondary to small vessel disease. There were significantly fewer cardioembolic strokes (hazard ratio [HR], 0.40 [95% CI, 0.20-0.78]; P = .005) and embolic strokes of undetermined source (HR, 0.30 [95% CI, 0.12-0.74]; P = .006) in the combination therapy group compared with the aspirin-only group. A trend for reduction in strokes secondary to small vessel disease (HR, 0.36 [95% CI, 0.12-1.14]; P = .07) was not statistically significant. No significant difference was observed between the 2 groups in strokes secondary to greater than 50% carotid artery stenosis (HR, 0.85 [95% CI, 0.45-1.60]; P = .61). Rivaroxaban, 5 mg, twice daily showed a trend for reducing cardioembolic strokes compared with aspirin (HR, 0.57 [95% CI, 0.31-1.03]; P = .06) but was not associated with reducing other stroke subtypes. Conclusions and Relevance: For patients with systemic atherosclerosis, low-dose rivaroxaban plus aspirin was associated with large, significant reductions in cardioembolic strokes and embolic strokes of undetermined source. However, these results of exploratory analysis need to be independently confirmed before influencing clinical practice. Trial Registration: ClinicalTrials.gov identifier: NCT01776424.


Assuntos
Aspirina/administração & dosagem , Embolia Intracraniana/complicações , Rivaroxabana/administração & dosagem , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/etiologia , Aterosclerose/complicações , Fibrilação Atrial/complicações , Estenose das Carótidas/complicações , Método Duplo-Cego , Quimioterapia Combinada , Inibidores do Fator Xa/administração & dosagem , Cardiopatias/complicações , Humanos
9.
Georgian Med News ; (294): 83-87, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31687955

RESUMO

The aim of the research was to investigate the relationship between cerebral microembolization and the development of postoperative cognitive impairment in patients after coronary artery bypass grafting with and without prophylactic administration of nitroglycerin at the end of artificial blood circulation. The study included 72 patients (43 male and 29 female) who had ACBPS using an ABCA. The patients were randomized into two clinical groups. The number of patients in the control group was 34 patients, in the study group - 38 patients. The study of the cognitive sphere was performed using a battery of clinical tests that included MSA and MMSE scales, Trail-making test, Grooved Pageboard, fine hands-motor test, 10 words test by AR Luria, Wexler's test, Schultz tables. The assessment was carried out on a day before the intervention and on the fifth day after the surgical intervention. It was shown that by all patients undergoing aorto-coronary bypass syrgery microembolization within the cerebral blood flow had been determined. The vast majority of microemboli is formed at the beginning of artificial blood circulation, at the moment of clamping aorta, as well as during the restoration of effective cardiac activity. Intraoperative microembolization of cerebral blood flow in excess of 750 microemboli leads to clinically significant deterioration of the brain functions in the early postoperative period. When used as a peripheral vasodilator, nitroglycerin, at a dose of 8-10 µg/kg*min in high (120-130%) volume perfusion rate, decreases the number of microemboluses in the basin of СМА by 2.4%.


Assuntos
Aorta/diagnóstico por imagem , Substitutos Sanguíneos , Ponte Cardiopulmonar/efeitos adversos , Disfunção Cognitiva/etiologia , Ponte de Artéria Coronária/efeitos adversos , Embolia Intracraniana/psicologia , Infarto do Miocárdio/cirurgia , Idoso , Idoso de 80 Anos ou mais , Ponte Cardiopulmonar/métodos , Circulação Cerebrovascular , Disfunção Cognitiva/diagnóstico por imagem , Disfunção Cognitiva/epidemiologia , Disfunção Cognitiva/psicologia , Ponte de Artéria Coronária/métodos , Feminino , Humanos , Embolia Intracraniana/complicações , Embolia Intracraniana/diagnóstico por imagem , Embolia Intracraniana/epidemiologia , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/sangue , Avaliação de Processos e Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle
10.
Stroke ; 50(12): 3360-3368, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31658903

RESUMO

Background and Purpose- Due to chronic hypoperfusion, cervical atherosclerosis may promote cerebral collateral circulation. We hypothesized that patients with ischemic stroke due to cervical carotid atherosclerosis have a more extensive collateral circulation and better outcomes than patients with cardioembolism. We tested this hypothesis in a population of patients who underwent endovascular treatment for large vessel occlusion. Methods- From the MR-CLEAN Registry (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands), we selected consecutive adult endovascular treatment patients (March 2014 to June 2016) with acute ischemic stroke due to anterior circulation large vessel occlusion and compared patients with cervical carotid artery stenosis >50% to those with cardioembolic etiology. The primary outcome was collateral score, graded on a 4-point scale. Secondary outcomes included the modified Rankin Scale (mRS) score and mortality at 90 days. We performed multivariable regression analyses and adjusted for potential confounders. Results- Of 1627 patients in the Registry, 190 patients with cervical carotid atherosclerosis and 476 with cardioembolism were included. Patients with cervical carotid atherosclerosis were younger (median 69 versus 76 years, P<0.001), more often male (67% versus 47%, P<0.001), more often had an internal carotid artery terminus occlusion (33% versus 18%, P<0.001), and a lower prestroke mRS (mRS score, 0-2; 96% versus 85%, P<0.001), than patients with cardioembolism. Stroke due to cervical carotid atherosclerosis was associated with higher collateral score (adjusted common odds ratio, 1.67 [95% CI, 1.17-2.39]) and lower median mRS at 90 days (adjusted common odds ratio, 1.45 [95% CI, 1.03-2.05]) compared with cardioembolic stroke. There was no statistically significant difference in proportion of mRS 0-2 (aOR, 1.36 [95% CI, 0.90-2.07]) or mortality at 90 days (aOR, 0.80 [95% CI, 0.48-1.34]). Conclusions- Patients with stroke due to cervical carotid atherosclerosis had a more extensive cerebral collateral circulation and a slightly better median mRS at 90 days than patients with cardioembolic stroke.


Assuntos
Encéfalo/irrigação sanguínea , Doenças das Artérias Carótidas/complicações , Circulação Colateral , Embolia Intracraniana/complicações , Acidente Vascular Cerebral/etiologia , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros
11.
Neurol Res ; 41(11): 1034-1042, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31584350

RESUMO

Objectives: To investigate the thrombolysis with recombinant human prourokinase (rhPro-UK) on thromboembolic stroke in rats at different therapeutic time windows (TTW). Methods: Rats were subjected to embolic middle cerebral artery occlusion. RhPro-UK and positive control drugs rt-PA,UK were administered 3 h, 4.5 h, 6 h after inducing thromboem-bolic stroke. Neurological deficit scoring (NDS) was evaluated at 6 h and 24 h after the treatment. The lesion volume in cerebral hemispheres was measured by MRI scanning machine after 6 h of thrombolysis, and the infarct volume was measured by TTC stain, together with hemorrhagic volume quantified by a spectrophotometric assay after 24 h of thrombolysis. Results: RhPro-UK 10, 20 × 104 U/kg significantly improved the NDS after cerebral thromboembolism in rats at 3 h, 4.5 h TTW, and at the 6 h TTW, the NDS was improved by 28.0% (P = 0.0690) and 29.2% (P = 0.0927) at 6 h and 24 h after rhPro-UK 20 ×104 U/kg administration, respectively. RhPro-UK 10, 20 × 104 U/kg significantly reduced the brain lesions measured by MRI at 3 h and 4.5 h TTW. RhPro-UK 10, 20 × 104 U/kg significantly reduced the cerebral infarction measured by TTC at 3 h, 4.5 h TTW. There was no increase in cerebral hemorrhage compared with untreated group after rhPro-UK administration. Conclusions: RhPro-UK had an obvious therapeutic effect on ischemic stroke caused by thrombosis, and could be started within 4.5 h TTW with less side effects of cerebral hemorrhage than that of UK.


Assuntos
Hemorragia Cerebral/tratamento farmacológico , Embolia Intracraniana/tratamento farmacológico , Acidente Vascular Cerebral/tratamento farmacológico , Ativador de Plasminogênio Tecidual/farmacologia , Animais , Hemorragia Cerebral/patologia , Modelos Animais de Doenças , Infarto da Artéria Cerebral Média/complicações , Infarto da Artéria Cerebral Média/tratamento farmacológico , Embolia Intracraniana/complicações , Masculino , Ratos Sprague-Dawley , Acidente Vascular Cerebral/complicações , Tromboembolia/complicações , Tromboembolia/tratamento farmacológico , Terapia Trombolítica/métodos , Fatores de Tempo
12.
Neurology ; 93(23): e2094-e2104, 2019 12 03.
Artigo em Inglês | MEDLINE | ID: mdl-31662492

RESUMO

OBJECTIVE: A tool to stratify the risk of stroke recurrence in patients with embolic stroke of undetermined source (ESUS) could be useful in research and clinical practice. We aimed to determine whether a score can be developed and externally validated for the identification of patients with ESUS at high risk for stroke recurrence. METHODS: We pooled the data of all consecutive patients with ESUS from 11 prospective stroke registries. We performed multivariable Cox regression analysis to identify predictors of stroke recurrence. Based on the coefficient of each covariate of the fitted multivariable model, we generated an integer-based point scoring system. We validated the score externally assessing its discrimination and calibration. RESULTS: In 3 registries (884 patients) that were used as the derivation cohort, age, leukoaraiosis, and multiterritorial infarct were identified as independent predictors of stroke recurrence and were included in the final score, which assigns 1 point per every decade after 35 years of age, 2 points for leukoaraiosis, and 3 points for multiterritorial infarcts (acute or old nonlacunar). The rate of stroke recurrence was 2.1 per 100 patient-years (95% confidence interval [CI] 1.44-3.06) in patients with a score of 0-4 (low risk), 3.74 (95% CI 2.77-5.04) in patients with a score of 5-6 (intermediate risk), and 8.23 (95% CI 5.99-11.3) in patients with a score of 7-12 (high risk). Compared to low-risk patients, the risk of stroke recurrence was significantly higher in intermediate-risk (hazard ratio [HR] 1.78, 95% CI 1.1-2.88) and high-risk patients (HR 4.67, 95% CI 2.83-7.7). The score was well-calibrated in both derivation and external validation cohorts (8 registries, 820 patients) (Hosmer-Lemeshow test χ2: 12.1 [p = 0.357] and χ2: 21.7 [p = 0.753], respectively). The area under the curve of the score was 0.63 (95% CI 0.58-0.68) and 0.60 (95% CI 0.54-0.66), respectively. CONCLUSIONS: The proposed score can assist in the identification of patients with ESUS at high risk for stroke recurrence.


Assuntos
Medição de Risco/métodos , Acidente Vascular Cerebral , Adulto , Idoso , Feminino , Humanos , Embolia Intracraniana/complicações , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Recidiva , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia
13.
Stroke ; 50(12): 3625-3627, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31537192

RESUMO

Background and Purpose- Patients with acute cerebral infarcts in multiple arterial territories (MACI) represent a substantial portion of the stroke population. There are no data on short-term outcome and in-hospital complications in patients with MACI. We compared patients with MACI with patients having acute cerebral infarct(s) in a single arterial territory. Methods- We analyzed 3343 patients with diffusion-weighted imaging-confirmed acute cerebral infarcts. MACI was defined as at least 2 acute cerebral ischemic lesions in at least 2 arterial cerebral territories. Patients with MACI were compared with patients with acute cerebral infarct(s) in a single arterial territory for relevant in-hospital complications and short-term outcome, namely National Institutes of Health Stroke Scale and modified Rankin Scale at day 7 after admission or at discharge when earlier. Results- A total of 311 patients (9.3%) met the definition of MACI. Both median National Institutes of Health Stroke Scale (2 [1-7] versus 1 [0-4]) and modified Rankin Scale (3 [1-4] versus 2 [1-3]) were higher in patients with MACI. MACI was independently associated with higher National Institutes of Health Stroke Scale and modified Rankin Scale. Deep venous thrombosis, myocardial infarction, and any complications were more frequent in patients with MACI. Conclusions- In-hospital complications were more frequent in patients with MACI, which may adversely affect short-term clinical and functional outcome. Closer follow-up of patients with MACI during hospitalization may prevent such events and negative progression.


Assuntos
Atividades Cotidianas , Infarto Cerebral/patologia , Idoso , Idoso de 80 Anos ou mais , Anticolesterolemiantes/uso terapêutico , Anticoagulantes/uso terapêutico , Estudos de Casos e Controles , Infarto Cerebral/diagnóstico por imagem , Infarto Cerebral/etiologia , Infarto Cerebral/terapia , Doenças de Pequenos Vasos Cerebrais/complicações , Imagem de Difusão por Ressonância Magnética , Feminino , Humanos , Embolia Intracraniana/complicações , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Inibidores da Agregação de Plaquetas/uso terapêutico , Prognóstico , Índice de Gravidade de Doença , Trombectomia , Trombose Venosa/epidemiologia
15.
Emerg Med J ; 36(7): 415-422, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31320334

RESUMO

CLINICAL INTRODUCTION: An 88-year-old woman presented with acute onset of involuntary limb movements for one day. Two days prior she had fallen a suffered a left hip contusion but no head trauma. There was no fever or difficulty breathing. Her heart rate was 72 bpm with blood pressure of 109/68 mm Hg. Physical examination revealed restricted left hip motion due to pain and a sustained twisted posture of the upper extremity without paresis. Glasgow Coma Scale was 15, and there was no evidence of Kernig's or Brudzinski's sign. She underwent a hip X-ray and non-contrast CT scan (figures 1 and 2).emermed;36/7/415/F1F1F1Figure 1Anteroposterior X-radiograph of the hip.emermed;36/7/415/F2F2F2Figure 2A non-contrast brain CT. QUESTION: What is the most likely cause of the clinical presentation?Acute meningitisCerebral fat embolismHaemorrhagic strokeHypertensive encephalopathy For answer see page 2 For question see page 1.


Assuntos
Embolia Gordurosa/complicações , Embolia Intracraniana/complicações , Perna (Membro)/anormalidades , Transtornos dos Movimentos/etiologia , Idoso de 80 Anos ou mais , Embolia Gordurosa/epidemiologia , Feminino , Humanos , Embolia Intracraniana/epidemiologia , Perna (Membro)/diagnóstico por imagem , Perna (Membro)/fisiopatologia , Imagem por Ressonância Magnética/métodos , Transtornos dos Movimentos/epidemiologia , Radiografia/métodos , Tomografia Computadorizada por Raios X/métodos
17.
JAAPA ; 32(6): 26-28, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31136397

RESUMO

Bilateral anterior opercular syndrome, also known as Foix-Chavany-Marie syndrome, is relatively rare and is characterized by inability of voluntary activation of facial, lingual, pharyngeal, and masticatory muscles with preserved automatic and reflex movements such as smiling and yawning. The syndrome is caused by bilateral lesions of the anterior opercula and results in severe impairments with speech and swallowing. This article describes a patient with bilateral anterior opercular syndrome secondary to embolic strokes and how neuro-rehabilitation improved symptoms.


Assuntos
Transtornos de Deglutição/reabilitação , Disartria/reabilitação , Paralisia Facial/reabilitação , Reabilitação Neurológica/métodos , Fonoterapia/métodos , Idoso , Encéfalo/diagnóstico por imagem , Transtornos de Deglutição/etiologia , Disartria/etiologia , Paralisia Facial/etiologia , Humanos , Embolia Intracraniana/complicações , Embolia Intracraniana/diagnóstico por imagem , Masculino , Sepse/complicações , Tomografia Computadorizada por Raios X
18.
J Clin Neurosci ; 66: 277-279, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31097380

RESUMO

A 72-year-old man without obvious risk factors initially presented with acute ischemic stroke and fever, without concomitant infection. Broad spectrum antibiotic therapy was initiated. Transthoracic and Transesophageal echocardiography, and cardiac MRI revealed a 20 mm round mass attached to the anterior mitral valve leaflet, suggesting the diagnosis of a benign cardiac tumor or a vegetation. At the site of infarction an abscess of 11 mm in diameter developed 30 days later. The patient underwent surgical valve repair for the prevention of further embolic complications. Histology revealed a cardiac papillary fibroelastoma (PFE). He made complete clinical recovery. Secondary abscess formation after ischemic stroke is rare: 11 other cases have been reported. Because they develop at the site of a previous ischemic infarct, these abscesses usually do not manifest by additional neurologic deficits, making difficult their diagnosis. In most cases a concomitant infection cannot be individualized. Even if these abscesses are a rare entity, patients with cerebral infarct presenting with fever must be closely follow-up with cerebral imaging. Even if PFE is a rare cardiac source of embolic stroke, it should be considered in the differential diagnosis of stroke in a patient where an alternative etiology has not been established.


Assuntos
Abscesso Encefálico/diagnóstico por imagem , Isquemia Encefálica/diagnóstico por imagem , Fibroma/diagnóstico por imagem , Neoplasias Cardíacas/diagnóstico por imagem , Embolia Intracraniana/diagnóstico por imagem , Acidente Vascular Cerebral/diagnóstico por imagem , Idoso , Abscesso Encefálico/complicações , Abscesso Encefálico/cirurgia , Isquemia Encefálica/complicações , Isquemia Encefálica/cirurgia , Diagnóstico Diferencial , Fibroma/cirurgia , Neoplasias Cardíacas/complicações , Neoplasias Cardíacas/cirurgia , Humanos , Embolia Intracraniana/complicações , Embolia Intracraniana/cirurgia , Masculino , Músculos Papilares/diagnóstico por imagem , Músculos Papilares/cirurgia , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/cirurgia
19.
Herz ; 44(4): 289-295, 2019 Jun.
Artigo em Alemão | MEDLINE | ID: mdl-31062047

RESUMO

The clinical construct of embolic stroke of unknown source (ESUS) was first described in 2014. It is defined as cryptogenic ischemic stroke after the exclusion of a lacunar infarct, a significant (≥50%) stenosis of extracranial or intracranial arteries and a cardiac source of embolism. Initially, there was hope that these patients would benefit from anticoagulation. This was based on the suspicion that imaging criteria of stroke mimic features of embolism from cardiac sources or the great arteries. In two large randomized trials with 12,600 patients neither rivaroxaban nor dabigatran could reduce the risk of recurrent stroke. Based on these results, current research is focused on paroxysmal atrial fibrillation as a potential cause of stroke in these patients. Several randomized trials could show that by prolongation of monitoring to 30 days atrial fibrillation can be detected in approximately 10% of the patients. Using continuous monitoring (e. g. by implantable loop recorders) atrial fibrillation can even be detected in one quarter of the patients. Not all stroke patients can receive such an intensive monitoring. Therefore, this article summarizes the evidence and presents the resulting recommendations for patient selection and staged rhythm diagnostics and discusses a recently presented algorithm of an expert group for use in daily clinical practice.


Assuntos
Fibrilação Atrial , Embolia Intracraniana , Acidente Vascular Cerebral , Fibrilação Atrial/complicações , Humanos , Embolia Intracraniana/complicações , Embolia Intracraniana/diagnóstico , Embolia Intracraniana/etiologia , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia
20.
Int J Stroke ; 14(9): 871-877, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-30917776

RESUMO

BACKGROUND: Recent prospective registration studies of transient ischemic attack in Western countries demonstrated that large artery atherosclerosis is the highest risk etiology for early stroke recurrence under urgent evaluation and treatment. On the other hand, some limited transient ischemic attack studies from East Asian countries showed transient ischemic attack patients due to small vessel occlusion were at a higher early stroke risk. AIMS: We aimed to assess the risk for early stroke in small vessel occlusion-transient ischemic attack patients in a Japanese large transient ischemic attack registry. METHODS: We analyzed the data of a prospective Japanese transient ischemic attack registry including 1320 transient ischemic attack patients within seven days after onset. Small vessel occlusion-transient ischemic attack was defined as the presence of lacunar transient ischemic attack syndrome, without other etiologies. The outcome measure was recurrent stroke within 30 days after transient ischemic attack. The predictors of 30-day recurrent stroke were estimated using the Cox proportional hazards model. RESULTS: The study population had a mean age of 69 ± 12 years and 470 were women. Recurrent stroke was observed in 61 patients (4.6%), and the highest rate was observed with small vessel occlusion-transient ischemic attack (7.8%), followed by large artery atherosclerosis (5.4%). In multivariate analysis, recurrent stroke was independently associated with small vessel occlusion-transient ischemic attack (hazard ratio (HR): 2.01, 95% confidence interval (CI): 1.19-3.35), higher systolic blood pressure (HR: 1.18, 95% CI: 1.08-1.28), and presentation within 3 h after onset (HR: 2.21, 95% CI: 1.27-4.04). Furthermore, small vessel occlusion-transient ischemic attack with acute small deep infarct on diffusion-weighted imaging was a stronger predictor of recurrent stroke (HR: 4.87, 95% CI: 2.09-10.0). CONCLUSION: Small vessel occlusion-transient ischemic attack, especially with acute small deep infarct, had a higher early stroke risk compared with other etiologies in Japanese transient ischemic attack patients who received early management.


Assuntos
Arteriosclerose Intracraniana/complicações , Embolia Intracraniana/complicações , Ataque Isquêmico Transitório/etiologia , Acidente Vascular Cerebral Lacunar/complicações , Acidente Vascular Cerebral/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Angiografia Cerebral , Imagem de Difusão por Ressonância Magnética , Ecocardiografia , Eletrocardiografia , Feminino , Humanos , Arteriosclerose Intracraniana/epidemiologia , Embolia Intracraniana/epidemiologia , Ataque Isquêmico Transitório/epidemiologia , Japão/epidemiologia , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Modelos de Riscos Proporcionais , Recidiva , Fatores de Risco , Acidente Vascular Cerebral Lacunar/epidemiologia
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