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3.
BMJ Case Rep ; 14(1)2021 Jan 25.
Artigo em Inglês | MEDLINE | ID: mdl-33495173

RESUMO

Surgery for prosthetic valve endocarditis in the mitral valve position is still challenging for surgeons. Reconstruction of the mitral annulus is useful for patients with a mitral annulus disputed by infection. Here, we report a redo mitral valve replacement using a collar-reinforced tissue valve, which was inserted into a mitral annulus reconstructed with a bovine patch. Though the preoperative blood culture detected Streptococcus anginosus, the intraoperative culture detected methicillin-resistant coagulase-negative staphylococci (MRCNS). MRCNS is rarely detected because of its indolent nature.


Assuntos
Antibacterianos/uso terapêutico , Endocardite Bacteriana/terapia , Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Estenose da Valva Mitral/cirurgia , Infecções Relacionadas à Prótese/terapia , Infecções Estafilocócicas/terapia , Infecções Estreptocócicas/terapia , Idoso , Ampicilina/uso terapêutico , Hemocultura , Daptomicina/uso terapêutico , Desbridamento , Ecocardiografia , Endocardite Bacteriana/complicações , Endocardite Bacteriana/microbiologia , Feminino , Humanos , Embolia Intracraniana/diagnóstico por imagem , Embolia Intracraniana/etiologia , Imagem por Ressonância Magnética , Resistência a Meticilina/fisiologia , Infecções Relacionadas à Prótese/microbiologia , Procedimentos Cirúrgicos Reconstrutivos , Reoperação , Staphylococcus/isolamento & purificação , Staphylococcus/fisiologia , Streptococcus anginosus/isolamento & purificação , Streptococcus anginosus/fisiologia , Sulbactam/uso terapêutico
4.
J Stroke Cerebrovasc Dis ; 30(3): 105542, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33341023

RESUMO

OBJECTIVE: To report six consecutive patients with confirmed coronavirus disease-2019 (COVID-19) who underwent Transcranial Doppler (TCD) ultrasonography evaluation for cerebral microemboli in the setting of suspected or confirmed acute ischemic stroke. METHODS: Patient data were obtained from medical records from Northwestern Memorial Hospital, Chicago, IL between May and June 2020. All patients with confirmed COVID-19 who underwent clinical TCD ultrasonography for microemboli detection were included. RESULTS: A total of eight TCD studies were performed in six patients with COVID-19 (4 men and 2 women, median age 65±5), four with confirmed ischemic stroke and two with refractory encephalopathy. Microemboli were detected in three male patients, two patients had suffered a confirmed ischemic stroke and one who developed prolonged encephalopathy. Microemboli of varying intensity were identified in multiple vascular territories in two patients, and microemboli persisted despite therapeutic anticoagulation in a third patient. Of the three patients without evidence of microemboli on TCD ultrasonography, two patients had suffered a confirmed ischemic stroke, while one remained with refractory encephalopathy. CONCLUSIONS: TCD ultrasonography for microemboli detection identified three patients with confirmed COVID-19 with evidence of cerebral arterial microemboli, including one who was therapeutically anticoagulated. TCD ultrasonography provides a non-invasive method for evaluating cerebral microemboli in patients with COVID-19 and may be useful in assessing response to treatment in cases with suspected or confirmed disorders of hypercoagulability. Further studies investigating the prevalence of cerebral microemboli and associated risk factors are needed to characterize their pathogenic mechanism and guide therapeutic interventions in hospitalized COVID-19 patients.


Assuntos
/complicações , Embolia Intracraniana/diagnóstico por imagem , Embolia Intracraniana/etiologia , Idoso , Anticoagulantes/uso terapêutico , Encefalopatias/diagnóstico por imagem , Encefalopatias/etiologia , Angiografia Cerebral , Diabetes Mellitus Tipo 2/complicações , Feminino , Humanos , Infarto da Artéria Cerebral Média/etiologia , Infarto da Artéria Cerebral Média/terapia , Embolia Intracraniana/terapia , /etiologia , Falência Renal Crônica/complicações , Masculino , Pessoa de Meia-Idade , Trombectomia , Ultrassonografia Doppler Transcraniana
5.
J Stroke Cerebrovasc Dis ; 29(11): 105197, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33066905

RESUMO

Several studies have suggested that non-stenotic carotid plaque was a risk factor for embolic stroke of undetermined source in some patients. However, individual backgrounds of these patients is unclear. We encountered a 64-years-old female with cerebral emboli, from an apparently stable non-stenotic carotid plaque (only 1.42mm thick) at the distal left common carotid artery, caused by violent tic movement of thyroid cartilage under well controlled dyslipidemia. Even though the plaque appeared thin and stable, mechanical stimulation could cause multiple, unnaturally localized emboli by stimulation-induced atherogenesis and plaque rupture, resulting in a misdiagnose of embolic stroke of undetermined source with non-stenotic carotid plaque.


Assuntos
Doenças das Artérias Carótidas/complicações , Embolia Intracraniana/etiologia , Placa Aterosclerótica , Acidente Vascular Cerebral/etiologia , Cartilagem Tireóidea/inervação , Tiques/complicações , Doenças das Artérias Carótidas/diagnóstico por imagem , Diagnóstico Diferencial , Erros de Diagnóstico , Feminino , Humanos , Embolia Intracraniana/diagnóstico por imagem , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Acidente Vascular Cerebral/diagnóstico por imagem , Cartilagem Tireóidea/diagnóstico por imagem , Tiques/diagnóstico por imagem , Tiques/fisiopatologia
6.
J Stroke Cerebrovasc Dis ; 29(10): 105178, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32912501

RESUMO

Aortogenic embolic stroke (AES) is an important stroke mechanism. However, as many stroke patients have aortic atheromatous lesions, it is unclear whether these lesions are the cause of these strokes. Cholesterol crystals are the solid, crystalline form of cholesterol that is found in atherosclerosis, but not in cardiac diseases such as atrial fibrillation, valvular diseases, and cardiomyopathy. Therefore, if a cholesterol crystal is found in a thrombus removed by mechanical thrombectomy (MT), this makes it possible to diagnose a patient as having an atheromatous lesion. Here, we report an AES case with a cholesterol crystal found in a thrombus removed by MT. A 67-year-old man was admitted due to consciousness disturbance, aphasia, and right hemiplegia. Diffusion-weighted imaging (DWI) showed a hyperintense area in the left frontal lobe, and magnetic resonance angiography demonstrated a branch occlusion of the left middle cerebral artery (MCA). MT was performed 1.5 h after stroke onset, with the thrombus removed and a left occluded MCA completely recanalized. Carotid duplex ultrasonography did not reveal any plaque in the carotid artery. Echocardiography did not show any abnormal function or findings, including thrombus. Transesophageal echocardiography showed a 4.9 mm atheromatous lesion at the aortic arch. Therefore, we suspected this patient as having an AES due to the embolic source of atheromatous lesion at the aortic arch. Pathological examination of the embolus revealed a cholesterol crystal cleft in the thrombus. Therefore, we diagnosed this patient as having AES caused by an atheromatous lesion at the aortic arch.


Assuntos
Doenças da Aorta/complicações , Aterosclerose/complicações , Colesterol/análise , Embolia Intracraniana/terapia , Trombose Intracraniana/terapia , Placa Aterosclerótica , Acidente Vascular Cerebral/terapia , Trombectomia , Idoso , Doenças da Aorta/diagnóstico por imagem , Doenças da Aorta/metabolismo , Aterosclerose/diagnóstico por imagem , Aterosclerose/metabolismo , Cristalização , Humanos , Embolia Intracraniana/diagnóstico por imagem , Embolia Intracraniana/etiologia , Trombose Intracraniana/diagnóstico por imagem , Trombose Intracraniana/etiologia , Masculino , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/etiologia , Resultado do Tratamento
7.
Vasc Endovascular Surg ; 54(8): 712-717, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32856558

RESUMO

BACKGROUND: Platelet inhibitory therapy is prescribed to prevent arterial thromboembolism in patients with atherosclerotic disease. Although taken by millions of people, around 30% are resistant to the treatment they are being prescribed. AIMS: To determine whether symptoms of cerebral ischemia, or pre-operative cerebral emboli, in patients admitted for a carotid endarterectomy were associated with resistance to aspirin or clopidogrel. METHODS: Venous blood from 133 patients immediately before carotid endarterectomy (CEA) was analyzed for resistance to aspirin and clopidogrel by multiplate impedance aggregometry. The number of emboli/hour entering the ipsilateral middle cerebral artery was counted by transcranial Doppler (TCD) on the day before surgery in 33 of these patients. RESULTS: Resistance was found in 21 (26.3%) of 100 patients taking aspirin and 14 (42%) of 33 taking clopidogrel. Mean (sd) residual platelet aggregation was significantly higher at 41.9(32) Au in patients who had suffered recent symptoms of cerebral ischemia compared with 30.8(16) Au in asymptomatic patients (p = 0.012). Residual platelet aggregation also correlated significantly with the number of emboli/hour counted by TCD in the ipsilateral middle cerebral artery (r = 0.45, p = 0.009). CONCLUSION: Antiplatelet resistance was associated with the frequency of cerebral emboli and recent symptoms of cerebral ischemia in patients with carotid disease. Definitive clinical studies are needed to explore whether testing for antiplatelet resistance should be undertaken routinely in patients starting platelet inhibitory therapy for cardiovascular disease.


Assuntos
Aspirina/uso terapêutico , Doenças das Artérias Carótidas/tratamento farmacológico , Clopidogrel/uso terapêutico , Resistência a Medicamentos , Infarto da Artéria Cerebral Média/prevenção & controle , Embolia Intracraniana/prevenção & controle , Inibidores da Agregação de Plaquetas/uso terapêutico , Agregação Plaquetária/efeitos dos fármacos , Aspirina/efeitos adversos , Doenças das Artérias Carótidas/sangue , Doenças das Artérias Carótidas/complicações , Doenças das Artérias Carótidas/diagnóstico por imagem , Clopidogrel/efeitos adversos , Feminino , Humanos , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Infarto da Artéria Cerebral Média/etiologia , Embolia Intracraniana/diagnóstico por imagem , Embolia Intracraniana/etiologia , Masculino , Inibidores da Agregação de Plaquetas/efeitos adversos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia Doppler Transcraniana
8.
Rinsho Shinkeigaku ; 60(9): 597-602, 2020 Sep 29.
Artigo em Japonês | MEDLINE | ID: mdl-32779594

RESUMO

An 82-year-old man with advanced lung cancer who had declined aggressive therapy was transferred to our hospital due to sudden-onset consciousness disturbance, global aphasia, and right hemiplegia. An electrocardiogram showed atrial fibrillation, and brain MRI and MRA revealed acute ischemic lesions of the left hemisphere and occlusion of the left internal carotid artery (ICA), respectively. We diagnosed acute ischemic stroke due to left ICA occlusion and performed endovascular thrombectomy, which resulted in complete recanalization of the left ICA after retrieval of the culprit embolus. Pathological examination of the retrieved thrombus revealed the presence of tumor tissue, as well as fibrin or red blood cells. Treatment was continued after admission, but the patient died of respiratory failure on day 40 of hospitalization. Autopsy revealed invasion of the tumor in the pulmonary vein, but not in the wall of the left atrium where thrombi were present. However, pathological examination of these thrombi in the left atrium revealed tumor tissue, along with fibrin or red blood cells. These findings suggest that the wall of the left atrium, in which lung cancer had not invaded, may be an incubator of a mixed embolus containing tumor tissue and thrombi in a case of cerebral embolism associated with both lung cancer and atrial fibrillation.


Assuntos
Fibrilação Atrial/complicações , Embolia Intracraniana/etiologia , Embolia Intracraniana/patologia , Neoplasias Pulmonares/complicações , Células Neoplásicas Circulantes , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/patologia , Idoso de 80 Anos ou mais , Arteriopatias Oclusivas/complicações , Autopsia , Artéria Carótida Interna , Evolução Fatal , Átrios do Coração , Humanos , Embolia Intracraniana/diagnóstico por imagem , Angiografia por Ressonância Magnética , Masculino , Acidente Vascular Cerebral/diagnóstico por imagem , Tomografia Computadorizada por Raios X
9.
J Stroke Cerebrovasc Dis ; 29(9): 105032, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32807444

RESUMO

BACKGROUND AND PURPOSE: Paroxysmal atrial fibrillation (PAF) has been suggested as a major cause of embolic stroke of undetermined source (ESUS). Transient atrial mechanical dysfunction (stunning) frequently occurs after conversion of atrial fibrillation to sinus rhythm. The study aim was to determine if reversible atrial mechanical dysfunction in ESUS could help elucidate the mechanism of stroke. METHODS: Eighty-five consecutive patients with acute ischemic stroke were enrolled according to the following inclusion criteria: [1] ≥55 years old; [2] normal sinus rhythm upon admission; [3] no apparent embolic source; and [4] transthoracic echocardiographic evaluation had been performed in both the early phase (<72 h) and late phase (>7 days) after stroke onset. There were 27 patients in the lacunar or atherothrombotic infarction group (controls), 22 in the PAF group, and 36 in the ESUS group. To determine atrial stunning, transmitral flow velocity profiles (Doppler peak E- [early diastolic] and A- [atrial systolic] waves) were obtained. RESULTS: In the early phase, an E/A velocity ratio ≥ 1.0 was less common in the control group (1 patient, 3.7%) than in the PAF group (19 patients, 86.4%; p < 0.001) and ESUS group (10 patients, 27.8%; p < 0.05). In the late phase, the E/A ratio decreased to less than 1.0 in six patients (31.6%) who had PAF and in eight patients (80.0%) who had ESUS. CONCLUSION: Transient atrial mechanical dysfunction could be a helpful finding for elucidating the stroke mechanism in patients with ESUS, and early echocardiographic assessment could improve its detection.


Assuntos
Fibrilação Atrial/complicações , Função do Átrio Esquerdo , Frequência Cardíaca , Embolia Intracraniana/etiologia , Acidente Vascular Cerebral/etiologia , Potenciais de Ação , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Diagnóstico Precoce , Ecocardiografia Doppler , Eletrocardiografia Ambulatorial , Feminino , Humanos , Embolia Intracraniana/diagnóstico , Embolia Intracraniana/fisiopatologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/fisiopatologia
10.
Medicine (Baltimore) ; 99(27): e20986, 2020 Jul 02.
Artigo em Inglês | MEDLINE | ID: mdl-32629713

RESUMO

RATIONALE: Cerebral carbon dioxide embolism (CCDE) is a rare cause of stroke and is a recognized life-threatening complication.CCDE may result from direct intravascular CO2 insufflation during surgery. Due to the lack of typical clinical manifestations, the disease is often missed or mistaken for another condition. The clinical signs and symptoms depend on the speed and volume of embolized gas entering the blood and the patient's condition. In particular, patent foramen ovale has been found to be associated, in rare cases, with the intraoperative entry of gas into the arterial system. PATIENT CONCERNS: In this report, we present the case of a 35-year-old woman with kidney cancer who underwent laparoscopic right partial nephrectomy. DIAGNOSIS: After the laparoscopic surgery, the patient was initially diagnosed with acute cerebral infarction. INTERVENTIONS: The patient was treated according to the standard method for treatment of acute cerebrovascular disease. OUTCOMES: Three days after the laparoscopic procedure, the patient gained consciousness, and she was discharged without any neurologic sequelae on postoperative day 12. LESSONS SUBSECTIONS AS PER STYLE: Due to the low incidence and sudden occurrence of CCDE, there is a strong likelihood of missed diagnosis or misdiagnosis, and it is; therefore, important to be aware of the risk. The findings from this report would be highly useful as a reference to clinicians in the future.


Assuntos
Dióxido de Carbono/efeitos adversos , Embolia Aérea/etiologia , Insuflação/efeitos adversos , Embolia Intracraniana/etiologia , Laparoscopia/efeitos adversos , Adulto , Dióxido de Carbono/sangue , Carcinoma de Células Renais/patologia , Carcinoma de Células Renais/cirurgia , Feminino , Humanos , Embolia Intracraniana/diagnóstico por imagem , Neoplasias Renais/patologia , Neoplasias Renais/cirurgia , Nefrectomia/efeitos adversos
12.
J Stroke Cerebrovasc Dis ; 29(8): 104975, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32689607

RESUMO

BACKGROUND: Structural left atrial and ventricular abnormalities on the electrocardiogram (ECG) and transthoracic echocardiogram (TTE) at the time of ischemic stroke have been associated with morbidity and mortality. Yet, the prognostic impact of the same in embolic stroke of undetermined source (ESUS), a relevant subtype of ischemic stroke with a unique pathophysiology, has not been well studied to date. Our aim was to assess the predictive impact of left atrio-ventricular ECG and TTE abnormalities on one-year hospital readmission after ESUS from an ongoing single center prospective stroke registry in the U.S. METHODS: We identified 369 ESUS patients who had at least 1 year of complete follow-up between 2013 and 2018. We examined the association of abnormal left atrio-ventricular findings on ECG and TTE, as well as basic demographic and clinical characteristics, measured at index admission with time to 1-year hospital readmission using Kaplan-Meier curves, log-rank tests, and Cox proportional hazards regression. RESULTS: Recurrent ischemic stroke and cardiovascular causes constituted 60% of all readmissions. Patients with left atrial dilation on TTE were more likely to readmitted within 1 year (HR 1.51; 95% CI, 1.04-2.21). Bundle branch block, pathologic Q-wave, and troponin elevation curves diverged, but were not significantly associated with readmission (log-rank p=0.34, p=0.08, p=0.42, respectively). CONCLUSIONS: Following ESUS, left atrial dilation on TTE was associated with 1-year overall hospital readmission, of which cardiovascular and cerebrovascular ischemic events, and heart failure were a notable proportion. Our data support ongoing studies of atrial cardiopathy in ESUS patients.


Assuntos
Função do Átrio Esquerdo , Remodelamento Atrial , Isquemia Encefálica/etiologia , Átrios do Coração/fisiopatologia , Cardiopatias/fisiopatologia , Embolia Intracraniana/etiologia , Readmissão do Paciente , Adulto , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/terapia , Ecocardiografia , Eletrocardiografia , Feminino , Átrios do Coração/diagnóstico por imagem , Cardiopatias/complicações , Cardiopatias/diagnóstico , Cardiopatias/terapia , Humanos , Embolia Intracraniana/diagnóstico , Embolia Intracraniana/terapia , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Recidiva , Sistema de Registros , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral , Fatores de Tempo , Estados Unidos
13.
Cerebrovasc Dis ; 49(3): 285-291, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32554958

RESUMO

INTRODUCTION: It is unclear which surrogate of atrial cardiopathy best predicts the risk of developing a recurrent ischemic stroke in embolic stroke of undetermined source (ESUS). Left atrial diameter (LAD) and LAD index (LADi) are often used as markers of left atrial enlargement in current ESUS research, but left atrial volume index (LAVi) has been found to be a better predictor of cardiovascular outcomes in other patient populations. OBJECTIVE: We aim to compare the performance of LAVi, LAD, and LADi in predicting the development of new-onset atrial fibrillation (AF) and stroke recurrence in ESUS. METHODS: Between October 2014 and October 2017, consecutive patients diagnosed with ESUS were followed for new-onset AF, ischemic stroke recurrence, and a composite outcome of occult AF and stroke recurrence. LAVi and LADi were measured by transthoracic echocardiogram; "high" LAVi was defined as ≥35 mL/m2 in accordance with American Society of Echocardiography guidelines. RESULTS: 185 ischemic stroke patients with ESUS were recruited and followed for a median duration of 2.1 years. Increased LAVi was associated with new-onset AF detection (aOR 1.08; 95% CI 1.03-1.14; p = 0.003) and stroke recurrence (aOR 1.05; 95% CI 1.01-1.10; p = 0.026). Patients with "high" LAVi had a higher likelihood of developing a composite of AF detection and stroke recurrence (HR 3.45; 95% CI 1.55-7.67; p = 0.002). No significant association was observed between LADi and either occult AF or stroke recurrence. CONCLUSIONS: LAVi is associated with new-onset AF and stroke recurrence in ESUS patients and may be a better surrogate of atrial cardiopathy.


Assuntos
Fibrilação Atrial/etiologia , Função do Átrio Esquerdo , Ecocardiografia , Átrios do Coração/diagnóstico por imagem , Embolia Intracraniana/terapia , Acidente Vascular Cerebral/terapia , Idoso , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Feminino , Átrios do Coração/fisiopatologia , Humanos , Embolia Intracraniana/diagnóstico por imagem , Embolia Intracraniana/etiologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Recidiva , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/etiologia , Fatores de Tempo , Resultado do Tratamento
14.
Medicine (Baltimore) ; 99(24): e20569, 2020 Jun 12.
Artigo em Inglês | MEDLINE | ID: mdl-32541485

RESUMO

RATIONALE: Fat embolism syndrome with cerebral fat embolism, rarely observed at our neurology department, is often associated with long bone fractures. Its diagnosis is based on medical history and supportive imaging data and is usually not difficult. However, its pathogenesis remains poorly understood. PATIENT CONCERNS: A 46-year-old woman was urgently presented to a nearby hospital because of a femur fracture caused by an accident. She rapidly developed somnolence and was suspected to have fat embolism syndrome. DIAGNOSES: Due to patients history of trauma and supportive imaging data, she was diagnosed with fat embolism syndrome obviously. However, severe brain damage confused our understanding of the pathogenesis. The subsequent diagnosis of fat embolism syndrome with patent foramen ovale provided a reasonable explanation. INTERVENTIONS: Initially, we did not consider the fact that the patient had developed fat embolism syndrome and thus designed a comprehensive treatment program for fat embolism syndrome. Then the routine cardiac and vascular ultrasound screening were followed up, but patent foramen ovale was diagnosed unexpectedly, which led to a more aggressive treatment of brain injury. OUTCOMES: After relevant symptomatic treatment continued for nearly 3 months, an overall improvement was observed. Patients consciousness was restored but language disorders were left. LESSONS: Clinicians should consider patent foramen ovale as the embolization pathway, particularly in young and middle-aged patients with cerebral embolism because it is often mistaken for a rare situation.


Assuntos
Embolia Gordurosa/etiologia , Fraturas do Fêmur/complicações , Forame Oval Patente/complicações , Embolia Intracraniana/etiologia , Feminino , Fraturas do Fêmur/diagnóstico por imagem , Forame Oval Patente/diagnóstico por imagem , Humanos , Embolia Intracraniana/diagnóstico por imagem , Pessoa de Meia-Idade
15.
J Interv Cardiol ; 2020: 3070427, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32518532

RESUMO

RESPOND is a prospective, single-arm study enrolling 1014 transcatheter aortic valve replacement (TAVR) patients. The objective of this analysis is to assess the impact of cerebral embolic protection (CEP) devices and prosthetic valve repositioning on the risk of neurologic complications in patients treated with the fully repositionable Lotus Valve in the RESPOND postmarket study. Valve repositioning and CEP use were at the operators' discretion. Stroke events were adjudicated by an independent medical reviewer. This analysis assessed the baseline differences among patients according to CEP use and valve repositioning and evaluated the neurological complications at 72 hours after TAVR, hospital discharge, and 30-day follow-up. A multivariate analysis was performed to identify the potential predictors of stroke. Of the 996 patients implanted with the Lotus Valve (mean age: 80.8 years, 50.8% female, STS score 6.0 ± 6.9), 92 cases (9.2%) used CEP. The overall rate of acute stroke/transient ischemic attack (TIA) was 3.0% at 72 hours after TAVR. The 72-hour stroke/TIA rate was 1.1% in patients who had CEP and 3.2% in those who did not. Use of CEP was associated with a 2.1% absolute reduction in the risk of acute neurological events (relative risk reduction: 65.6%), although the difference was not statistically significant (p=0.51). Repositioning of the Lotus Valve occurred in 313/996 procedures (31.4%). The 72-hour rate of stroke/TIA was similar in patients who had valve repositioning (2.9%) compared with those who did not (3.1%; p=0.86). The selective use of a CEP device in the RESPOND study was associated with a nonsignificantly lower risk for stroke within 72 hours. The use of the repositioning feature of the Lotus Valve did not increase the stroke risk.


Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Dispositivos de Proteção Embólica , Embolia Intracraniana , Complicações Pós-Operatórias , Risco Ajustado/métodos , Acidente Vascular Cerebral , Substituição da Valva Aórtica Transcateter , Idoso de 80 Anos ou mais , Desenho de Equipamento , Feminino , Próteses Valvulares Cardíacas/efeitos adversos , Humanos , Embolia Intracraniana/diagnóstico , Embolia Intracraniana/etiologia , Embolia Intracraniana/prevenção & controle , Masculino , Avaliação de Processos e Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/instrumentação , Substituição da Valva Aórtica Transcateter/métodos
17.
J Stroke Cerebrovasc Dis ; 29(7): 104849, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32402721

RESUMO

OBJECTIVE: To determine the diagnostic value of acute infarcts in multiple cerebral circulations (AIMCC) on MRI diffusion-weighted imaging (DWI) for cardioembolism (CE) stroke subtype in adult patients hospitalized with acute ischemic stroke, we conducted a systematic literature review and meta-analysis. METHODS: MEDLINE was searched via PubMed for articles reporting patients hospitalized with acute ischemic stroke with MRI DWI categorized as AIMCC vs other and use of Trial of Org 10172 in Acute Stroke Treatment (TOAST) Criteria for cardioembolism subtype. Measures of diagnostic accuracy were calculated from the retrieved studies. RESULTS: Seven eligible articles comprised 5813 patients. Bivariate random effects models estimated sensitivity 0.19 (95% CI, 0.13 to 0.27), specificity 0.89 (0.86 to 0.91), positive predictive value 0.37 (0.30 to 0.45), negative predictive value 0.76 (0.7 to 0.82), positive likelihood ratio 1.70 (1.13 to 2.57) and negative likelihood ratio 0.91 (0.83 to 1). INTERPRETATION: The pattern of AIMCC on DWI is of limited diagnostic value. It is not sufficiently accurate to exclude cardiac pathology by a negative test nor does a positive test indicate a major increase in the probability of identifying a potential cardioembolic source.


Assuntos
Infarto Cerebral/diagnóstico por imagem , Circulação Cerebrovascular , Imagem de Difusão por Ressonância Magnética , Cardiopatias/complicações , Embolia Intracraniana/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Infarto Cerebral/etiologia , Infarto Cerebral/fisiopatologia , Feminino , Cardiopatias/diagnóstico por imagem , Humanos , Embolia Intracraniana/etiologia , Embolia Intracraniana/fisiopatologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Reprodutibilidade dos Testes , Fatores de Risco
18.
J Stroke Cerebrovasc Dis ; 29(7): 104917, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32414582

RESUMO

BACKGROUND AND PURPOSE: The trajectory of cardiogenic emboli could be affected by anatomical and flow characteristics of the aortic arch. We aimed to study the relation between the different aortic arch patterns and the laterality of cardiogenic emboli. METHODS: 192 cardioembolic strokes were classified into 3 groups according to the type of the aortic arch; type 1 (n = 69), type 2 (n = 49), type 3 (n = 74). The side and site of the cerebral vessels occlusion were divided into anterior and posterior circulation strokes, and anterior strokes were further subdivided into right or left internal carotid, middle or anterior cerebral arteries occlusion. RESULTS: Overall, the anterior circulation embolic occlusions were more common than the posterior, and middle cerebral artery more commonly affected than internal carotid artery. The left side propensity was higher either in the total patients' pool or after segregation into atrial fibrillation (AF) and non AF cardio-embolic cases in all types of aortic arch except for type 1 aortic arch in the non AF cases. This propensity tended to get higher with advancement of the aortic arch types but failed to show statistically significant difference between the 3 arch types, however combination of type 2 and 3 arches into a single group showed statistically significant rise in the left side propensity in the total cardioembolic cases (P = 0.039) and in the non AF cardioembolic cases (P = 0.029). The bovine arch also showed increased left side propensity. CONCLUSION: Cardioemboli tends to have left anterior cerebrovascular predilection especially with AF. Different geometrical patterns of aortic arch branching seem to affect the laterality of cardioemboli and increase its left side predilection.


Assuntos
Aorta Torácica/diagnóstico por imagem , Aortografia/métodos , Angiografia por Tomografia Computadorizada , Cardiopatias/complicações , Embolia Intracraniana/etiologia , Acidente Vascular Cerebral/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Cardiopatias/diagnóstico por imagem , Humanos , Embolia Intracraniana/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico por imagem
20.
BMC Infect Dis ; 20(1): 381, 2020 May 27.
Artigo em Inglês | MEDLINE | ID: mdl-32460792

RESUMO

BACKGROUND: Clinicians may be less inclined to consider a diagnosis of cryptococcal meningitis in people without HIV infection or transplant-related immunosuppression. This may lead to a delay in diagnosis particularly if disseminated cryptococcal disease mimics cerebral septic emboli in injection drug use (IDU) leading to a search for endocarditis or other infectious sources. Though, IDU has been described as a potential risk for disseminated cryptococcal disease. CASE PRESENTATIONS: We present two cases of cryptococcal meningitis in IDU without HIV or other obvious immune deficits. Both patients presented with at least 2 weeks of headache and blurred vision. They developed central nervous system (CNS) vasculitis, one of which mimicked septic cerebral emboli, but both resulted with poor neurologic outcomes. CONCLUSIONS: IDU likely induces an underappreciated immune deficit and is a risk factor for developing cryptococcal meningitis. This diagnosis, which can mimic cerebral septic emboli through involvement of a CNS vasculitis, should be considered in the setting of IDU.


Assuntos
Drogas Ilícitas/efeitos adversos , Embolia Intracraniana/microbiologia , Meningite Criptocócica/diagnóstico , Transtornos Relacionados ao Uso de Substâncias/complicações , Adulto , Cryptococcus neoformans/genética , Cryptococcus neoformans/isolamento & purificação , Humanos , Embolia Intracraniana/diagnóstico , Embolia Intracraniana/etiologia , Embolia Intracraniana/imunologia , Masculino , Meningite Criptocócica/etiologia , Meningite Criptocócica/imunologia , Meningite Criptocócica/microbiologia , Pessoa de Meia-Idade , Projetos de Pesquisa , Fatores de Risco
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