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1.
Neurology ; 96(12): e1646-e1654, 2021 03 23.
Artigo em Inglês | MEDLINE | ID: mdl-33536272

RESUMO

OBJECTIVE: To analyze the relationship of lacunes with cortical cerebral microinfarcts (CMIs), to assess their association with vascular dysfunction, and to evaluate their effect on the risk of incident intracerebral hemorrhage (ICH) in cerebral amyloid angiopathy (CAA). METHODS: The count and topography of lacunes (deep/lobar), CMIs, and white matter hyperintensity (WMH) volume were retrospectively analyzed in a prospectively enrolled CAA cohort that underwent high-resolution research MRIs. The relationship of lacunes with CMIs and other CAA-related markers including time to peak (TTP) of blood oxygen level-dependent signal, an established measure of vascular dysfunction, was evaluated in multivariate models. Adjusted Cox regression models were used to investigate the relationship between lacunes and incident ICH. RESULTS: The cohort consisted of 122 patients with probable CAA without dementia (mean age, 69.4 ± 7.6 years). Lacunes were present in 31 patients (25.4%); all but one were located in lobar regions. Cortical CMIs were more common in patients with lacunes compared to patients without lacunes (51.6% vs 20.9%, p = 0.002). TTP was not associated with either lacunes or CMIs (both p > 0.2) but longer TTP response independently correlated with higher WMH volume (p = 0.001). Lacunes were associated with increased ICH risk in univariate and multivariate Cox regression models (p = 0.048 and p = 0.026, respectively). CONCLUSIONS: Our findings show a high prevalence of lobar lacunes, frequently coexisting with CMIs in CAA, suggesting that these 2 lesion types may be part of a common spectrum of CAA-related infarcts. Lacunes were not related to vascular dysfunction but predicted incident ICH, favoring severe focal vessel involvement rather than global ischemia as their mechanism.


Assuntos
Infarto Encefálico/epidemiologia , Angiopatia Amiloide Cerebral/complicações , Hemorragia Cerebral/epidemiologia , Acidente Vascular Cerebral Lacunar/epidemiologia , Idoso , Infarto Encefálico/etiologia , Angiopatia Amiloide Cerebral/patologia , Hemorragia Cerebral/etiologia , Feminino , Humanos , Lactente , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Retrospectivos , Acidente Vascular Cerebral Lacunar/etiologia
2.
BMJ Case Rep ; 14(1)2021 Jan 28.
Artigo em Inglês | MEDLINE | ID: mdl-33509861

RESUMO

We describe the case of a 21-year-old man with a background of sickle cell disease (SCD) who was on acute presentation in a sickle cell crisis required immediate intensive care admission with red blood cell exchange and ventilatory support. He had right frontal lobe infarcts and extensive bilateral deep white matter lesions most likely secondary to fat embolism. Inpatient investigations demonstrated a patent foramen ovale, explaining the route of spread of the fat embolus. He then had a transcatheter closure of the atrial defect. The patient needed prolonged inpatient rehabilitation. He was discharged from hospital in a wheelchair secondary to severe lower limb neurology and bilateral knee heterotopic ossification. He lives with the possibility of early onset dementia and cognitive decline, requiring constant care. The case highlights the multiple manifestations of SCD and their diverse and debilitating consequences.


Assuntos
Anemia Falciforme/fisiopatologia , Infarto Encefálico/fisiopatologia , Disfunção Cognitiva/fisiopatologia , Embolia Gordurosa/fisiopatologia , Leucoencefalopatias/fisiopatologia , Neuralgia/fisiopatologia , Polineuropatias/fisiopatologia , Quadriplegia/fisiopatologia , Anemia Falciforme/complicações , Anemia Falciforme/terapia , Infarto Encefálico/diagnóstico por imagem , Infarto Encefálico/etiologia , Disfunção Cognitiva/etiologia , Contratura/etiologia , Contratura/fisiopatologia , Ecocardiografia , Embolia Gordurosa/etiologia , Transfusão de Eritrócitos , Forame Oval Patente/complicações , Lobo Frontal/diagnóstico por imagem , Humanos , Unidades de Terapia Intensiva , Articulação do Joelho/diagnóstico por imagem , Leucoencefalopatias/diagnóstico por imagem , Leucoencefalopatias/etiologia , Imagem por Ressonância Magnética , Masculino , Neuralgia/etiologia , Ossificação Heterotópica/diagnóstico por imagem , Ossificação Heterotópica/etiologia , Ossificação Heterotópica/fisiopatologia , Plasma , Transfusão de Plaquetas , Polineuropatias/etiologia , Quadriplegia/etiologia , Adulto Jovem
3.
J Stroke Cerebrovasc Dis ; 30(3): 105567, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33385939

RESUMO

OBJECTIVES: Despite the proven efficacy of endovascular thrombectomy (EVT) for large vessel occlusion stroke, over half treated remain functionally disabled or die. Infarct topography may have implications for prognostication, patient selection, and the development of tissue-specific neuroprotective agents. We sought to quantify white matter injury in anterior circulation acute infarcts post-EVT to understand its significance and identify its determinants. MATERIALS AND METHODS: Demographics, history, presentations, and outcomes for consecutive patients treated with EVT were recorded in a prospectively maintained database at a single center. Acute infarct masks were coregistered to standard space. Standard atlases of white matter, cortex, and basal ganglia were used to determine region-specific infarct volumes. RESULTS: 167 individuals were identified with median age 69 years and 53% women. 85% achieved adequate reperfusion (TICI 2b-3) after EVT; 43% achieved 90-day functional independence (mRS 0-2). Median infarct volumes were 45cc (IQR 18-122) for total, 17cc (6-49) for white matter, 21cc (4-53) for cortex, and 5cc (1-8) for basal ganglia. The odds of 90-day mRS 0-2 were reduced in patients with larger white matter infarct volume (cc, OR=0.89, 95%CI=0.81-0.96), independent of cortex infarct volume, basal ganglia infarct volume, age, NIHSS, and TICI 2b-3 reperfusion. Reperfusion-to-MRI time was associated with white matter infarct volume (hr, ß=0.119, p=0.017), but not cortical or basal ganglia infarct volume. CONCLUSIONS: These data quantitatively describe region-specific infarct volumes after EVT and suggest the clinical relevance of white matter infarct volume as a predictor of long-term outcomes. Further study is warranted to examine delayed white matter infarction and the significance of specific white matter tracts.


Assuntos
Infarto Encefálico/diagnóstico por imagem , Procedimentos Endovasculares/efeitos adversos , Leucoencefalopatias/diagnóstico por imagem , Imagem por Ressonância Magnética , Trombectomia/efeitos adversos , Substância Branca/diagnóstico por imagem , Idoso , Infarto Encefálico/etiologia , Bases de Dados Factuais , Feminino , Humanos , Leucoencefalopatias/etiologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
4.
Int Heart J ; 62(1): 216-219, 2021 Jan 30.
Artigo em Inglês | MEDLINE | ID: mdl-33455990

RESUMO

A 14 year-old boy developed infective endocarditis of the mitral valve caused by Methicillin-sensitive Staphylococcus aureus and became comatose. Isolated basilar artery dissection was initially observed on the 3rd day by magnetic resonance imaging (MRI), ie, it did not exist on day 1. He underwent successful urgent mitral valve repair on the 5th day because of highly mobile vegetations and a newly emerged brain infarction under optimal antibiotic administration. Postoperatively, he recovered well and the basilar artery dissection was found to have recovered on an MRI on the 25th day without any specific intervention. This clinical course indicated that intracranial artery dissection may occur as a complication of infective endocarditis and supports the importance of the careful evaluation of brain MRI in patients with infective endocarditis.


Assuntos
Artéria Basilar/diagnóstico por imagem , Endocardite/complicações , Imagem por Ressonância Magnética/métodos , Valva Mitral/microbiologia , Adolescente , Antibacterianos/uso terapêutico , Artéria Basilar/patologia , Infarto Encefálico/diagnóstico por imagem , Infarto Encefálico/etiologia , Dissecação , Ecocardiografia/métodos , Endocardite/tratamento farmacológico , Humanos , Masculino , Valva Mitral/diagnóstico por imagem , Valva Mitral/cirurgia , Infecções Estafilocócicas/complicações , Infecções Estafilocócicas/tratamento farmacológico , Staphylococcus aureus/isolamento & purificação , Resultado do Tratamento
5.
Eur J Vasc Endovasc Surg ; 61(2): 239-245, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33358103

RESUMO

OBJECTIVE: Few data exist concerning the rate of silent cerebral ischaemic events following endovascular treatment of the aortic arch. The objective of this work was to quantify these lesions using the STEP registry (NCT04489277). METHODS: This multicentre retrospective cohort study included consecutive patients treated with an aortic endoprosthesis deployed in Ishimaru zone 0-3 and brain diffusion weighted magnetic resonance imaging (DW-MRI) within seven days following the procedure. DW-MRI was performed to identify the location and number of new silent brain infarctions (SBI). All endografts were carbon dioxide flushed prior to implantation. RESULTS: The study population included 91 patients (mean age, 69 years; men, 64%) from two academic centres treated between September 2018 and January 2020. The procedure was elective in 71 patients (78%). The treatment was performed for a dissection, degenerative aneurysm, or other aortic disease in 44 (49%), 34 (37%), and 13 (14%) patients, respectively. Endografts were deployed in zone 0, 1, 2 or 3 in 23 (25%), 10 (11%), 47 (52%), and 11 (12%) patients, respectively. Endografts were branched (25%), fenestrated (17%), or tubular (58%). At 30 days, there were no deaths or clinical strokes. On cerebral DW-MRI, a total of 245 SBI were identified in 45 patients (50%). Lesions were in the left hemisphere in 63% of the patients (153/245), predominantly in the middle territory (94/245). Deployment in zone 0-1 (p = .026), placement of a branched or fenestrated endograft (p = .038), a proximal endoprosthesis diameter ≥ 40 mm (p = .038), and an urgent procedure (p = .005) were significantly associated with the presence of SBI on univariable analysis, while urgent procedure was found to be an independent predictor on multivariable analysis (binary logistic regression) (p = .002). CONCLUSION: SBI following endovascular repair of the aortic arch is frequent, although there were no clinical strokes. Innovative strategies to reduce the risk of embolisation need to be developed.


Assuntos
Aorta Torácica/cirurgia , Doenças da Aorta/cirurgia , Implante de Prótese Vascular/efeitos adversos , Infarto Encefálico/etiologia , Procedimentos Endovasculares/efeitos adversos , Complicações Pós-Operatórias , Adulto , Idoso , Doenças Assintomáticas , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/métodos , Infarto Encefálico/diagnóstico por imagem , Infarto Encefálico/epidemiologia , Imagem de Difusão por Ressonância Magnética , Feminino , Humanos , Incidência , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/epidemiologia , Sistema de Registros , Estudos Retrospectivos
9.
J Stroke Cerebrovasc Dis ; 29(10): 105164, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32912544

RESUMO

INTRODUCTION: The incidence of lung cancer and acute ischemic stroke remains high in recent years, both of which occur mostly in people over 60 years old. In the present study, we aimed to further clarify the pathogenesis of lung cancer-associated acute ischemic stroke (LCA-AIS) by comparing and analyzing clinical characteristics of stroke patients with or without lung cancer. METHODS: A total of 51 patients with lung cancer were selected as the case group (LCSG), and 78 patients without cancer history were adopted as the control group (SG). The data collected in this study included sex, age, traditional cerebrovascular disease risk factors (TCDRFs), blood test index, imaging findings, etiological typing, and prognosis evaluation. SPSS21.0 software was used for statistical analysis. Normally distributed data were analyzed by t-test, and count data were analyzed by chi-square test or exact probability method. P < 0.05 was considered statistically significant. RESULTS: In the case group, the levels of plasma D-dimer, fibrinogen degradation products (FDPs) and NIHSS, as well as the mRS score and mortality of patients, were higher, while the levels of RBC, Hb and Hcy were lower compared with the control group. Imaging findings showed that multivessel involvement was more common in the case group, and the infarcts were more likely to be multiple and involved in both the anterior and posterior circulations. The TOAST classification of LCSG was dominated by stroke of undetermined etiology (SUE) and stroke of other determined etiology (SOE). Statistical analysis showed that the patients were more likely to suffer from acute ischemic stroke within 1 year after the diagnosis of lung cancer (41 cases, 80.39%). CONCLUSIONS: Hypercoagulability and acute multiple brain infarcts were more common in patients with LCA-AIS, and hypoproteinemia and hyponatremia were more likely to occur in these patients, leading to worse prognosis. Patients were most likely to have a stroke within 1 year after the diagnosis of lung cancer.


Assuntos
Infarto Encefálico/etiologia , Neoplasias Pulmonares/complicações , Tromboembolia/etiologia , Trombofilia/etiologia , Idoso , Biomarcadores/sangue , Infarto Encefálico/diagnóstico , Infarto Encefálico/mortalidade , Estudos de Casos e Controles , Avaliação da Deficiência , Feminino , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Humanos , Hiponatremia/diagnóstico , Hiponatremia/etiologia , Hipoproteinemia/diagnóstico , Hipoproteinemia/etiologia , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/mortalidade , Masculino , Pessoa de Meia-Idade , Prognóstico , Medição de Risco , Fatores de Risco , Tromboembolia/diagnóstico , Tromboembolia/mortalidade , Trombofilia/diagnóstico , Trombofilia/mortalidade , Fatores de Tempo
10.
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
11.
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
12.
Cerebrovasc Dis Extra ; 10(2): 76-83, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32726784

RESUMO

BACKGROUND: Treatment for acute ischemic stroke due to large vessel occlusion (LVO) with mild symptoms is under discussion. Although most patients have good outcomes, some patients deteriorate and have unfavorable results. Imaging findings that predict the prognosis of LVO with mild symptoms are needed to identify patients who require treatment. In this study, we focused on watershed infarctions (WSIs), because this clinical phenomenon quite sensitively reflects changes in cerebral blood flow. The purpose of this study was to assess positive rates of WSI on MRI findings in patients with internal carotid artery (ICA) occlusion, and compare WSI-positive rates between patients divided according to their clinical course. METHODS: We retrospectively collected data of 1,531 patients who presented with acute ischemic stroke between June 2006 and July 2019. Among them, we chose symptomatic ICA occlusion patients with a past history of atrial fibrillation who were treated conservatively. We divided these patients into two groups, those with maintenance or improvement in their NIHSS score after hospitalization, and those whose NIHSS score worsened. We compared WSI-positive rates between these two groups. RESULTS: Thirty-seven of the 1,531 patients were included in this study. Of them, total NIHSS score was maintained or improved in 8 patients (group A), 3 of whom (37.5%) had internal watershed infarctions (IWIs). In group B, consisting of patients whose NIHSS score worsened by >2 at 7 days from symptom onset, 24 (82.8%) had IWIs. Group A thus had statistically lower IWI positivity rates than group B (p = 0.02). Three patients (37.5%) in group A had cortical watershed infarctions (CWIs), while 27 patients in group B (93.1%) had CWIs. Group A thus had a significantly lower CWI positivity rate than group B (p = 0.002). CONCLUSION: In patients with mildly symptomatic ICA occlusion, CWIs and IWIs might be key signs for predicting neurological deterioration after hospitalization.


Assuntos
Infarto Encefálico/diagnóstico por imagem , Artéria Carótida Interna , Estenose das Carótidas/complicações , Angiografia Cerebral , Circulação Cerebrovascular , Imagem de Difusão por Ressonância Magnética , Angiografia por Ressonância Magnética , Idoso , Idoso de 80 Anos ou mais , Infarto Encefálico/etiologia , Infarto Encefálico/fisiopatologia , Infarto Encefálico/terapia , Artéria Carótida Interna/diagnóstico por imagem , Artéria Carótida Interna/fisiopatologia , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/fisiopatologia , Estenose das Carótidas/terapia , Avaliação da Deficiência , Progressão da Doença , Feminino , Humanos , Masculino , Valor Preditivo dos Testes , Recuperação de Função Fisiológica , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
13.
J Card Surg ; 35(8): 1927-1932, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32667074

RESUMO

BACKGROUND AND AIM: There is no report on silent brain infarction (SBI) after minimally invasive cardiac surgery (MICS) with retrograde perfusion. Thus, the current study aimed to investigate the incidence of SBI after MICS using magnetic resonance imaging (MRI). METHODS: This study included 174 patients who underwent MICS with retrograde perfusion between July 2014 and July 2018. Preoperative computed tomography (CT) angiography was routinely performed and vascular pathology was evaluated for patient selection. Postoperative MRI was performed to investigate the occurrence of SBI. RESULTS: Out of the total 174 patients, 26 (14.9%) presented with SBI. A total of 61 SBI lesions were found in the 26 patients; of these, 34 (56%) SBI lesions were in the right hemisphere and 27 (44%) in the left hemisphere. SBIs were primarily observed in the posterior cerebral artery territory. Multivariate analysis revealed aortic stenosis to be the only risk factor of SBI. CONCLUSIONS: Retrograde perfusion via femoral cannulation may not increase the incidence of SBI in selected MICS patients based on preoperative CT findings.


Assuntos
Infarto Encefálico/etiologia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Perfusão/efeitos adversos , Perfusão/métodos , Complicações Pós-Operatórias/etiologia , Idoso , Estenose da Valva Aórtica , Infarto Encefálico/diagnóstico por imagem , Infarto Encefálico/epidemiologia , Angiografia por Tomografia Computadorizada , Feminino , Humanos , Incidência , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/epidemiologia , Fatores de Risco
14.
PLoS One ; 15(7): e0235276, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32673331

RESUMO

Smoking cessation reduces the cardiovascular risk but increases body weight. We investigated the risk of subsequent myocardial infarction and ischemic stroke according to weight gain after smoking cessation, using a nationwide population based cohort. We enrolled 3,797,572 Korean adults aged over 40 years who participated in national health screenings between 2009 and 2010. Subjects who quit smoking were classified into three subgroups according to the weight change between baseline and 4 years prior. Myocardial infarctions and ischemic strokes were followed until the end of 2015. We compared the hazard ratios among smoking cessation subgroups, non-smokers, and current smokers. The mean changes in weight (1.5 ± 3.9 kg) of the smoking cessation group were higher than those of the other groups (p < 0.0001). A total of 31,277 and 46,811 subjects were newly diagnosed with myocardial infarction and ischemic stroke, respectively. Regardless of weight change, all subgroups of smoking cessation had significantly less risk than current smokers. The subgroup of smoking cessation with weight gain over 4kg showed the lowest risk for myocardial infarctions (hazard ratio 0.646, 95% confidence interval 0.583-0.714, p < 0.0001) and ischemic strokes (hazard ratio 0.648, 95% confidence interval 0.591-0.71, p < 0.0001) after multivariable adjustment. In conclusion, weight gain after smoking cessation did not adversely affect the cardiovascular protective effect.


Assuntos
Infarto Encefálico/epidemiologia , Infarto do Miocárdio/epidemiologia , Abandono do Hábito de Fumar/estatística & dados numéricos , Fumar/efeitos adversos , Ganho de Peso , Adulto , Idoso , Infarto Encefálico/etiologia , Infarto Encefálico/prevenção & controle , Ex-Fumantes/estatística & dados numéricos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/prevenção & controle , não Fumantes/estatística & dados numéricos , Modelos de Riscos Proporcionais , República da Coreia/epidemiologia , Fatores de Risco , Fumantes/estatística & dados numéricos
16.
J Cardiovasc Pharmacol Ther ; 25(4): 346-353, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32292050

RESUMO

BACKGROUND: We investigated whether the cardioprotective, volatile gas anesthetic agent, isoflurane, could improve survival and organ function from hemorrhagic shock in an experimental rat model, compared to standard nonvolatile anesthetic agent ketamine/xylazine. METHODS: Sprague Dawley rats (both genders) were randomized to receive either intraperitoneal ketamine/xylazine (K/X, 90 and 10 mg/kg; n = 12) or isoflurane (5% isoflurane induction and 2% maintenance in room air; n = 12) for anesthesia. Blood was withdrawn to maintain mean arterial blood pressure at 30 mm Hg for 1 hour, followed by 30 minutes of resuscitation with shed blood. Rats were allowed to recover and survive for 6 weeks. RESULTS: During the shock phase, the total withdrawn blood volume (expressed as % of estimated total blood volume) to maintain a level of hypotension of 30 mm Hg was significantly higher in the isoflurane group (51.0% ± 1.5%) than in the K/X group (45.3% ± 1.8%; P = .023). Recovery of blood pressure during the resuscitation phase was significantly improved in the isoflurane group compared to the K/X group. The survival rate at 6 weeks was 1 (8.3%) of 12 in rats receiving K/X and 10 (83.3%) of 12 in rats receiving isoflurane (P < .001). Histology performed at 6 weeks demonstrated brain infarction in the 1 surviving rat receiving K/X; no brain infarction occurred in the 10 surviving rats that received isoflurane. No infarction was detected in heart, lung, liver, or kidneys among the surviving rats. CONCLUSIONS: Isoflurane improved blood pressure response to resuscitation and resulted in significantly higher long-term survival rate.


Assuntos
Anestésicos Dissociativos/farmacologia , Anestésicos Inalatórios/farmacologia , Pressão Sanguínea/efeitos dos fármacos , Infarto Encefálico/prevenção & controle , Encéfalo/efeitos dos fármacos , Isoflurano/farmacologia , Ketamina/farmacologia , Ressuscitação , Choque Hemorrágico/tratamento farmacológico , Animais , Encéfalo/patologia , Infarto Encefálico/etiologia , Infarto Encefálico/patologia , Modelos Animais de Doenças , Feminino , Masculino , Ratos Sprague-Dawley , Choque Hemorrágico/complicações , Choque Hemorrágico/fisiopatologia , Fatores de Tempo
17.
Cochrane Database Syst Rev ; 4: CD012389, 2020 04 06.
Artigo em Inglês | MEDLINE | ID: mdl-32250453

RESUMO

BACKGROUND: Sickle cell disease (SCD) is one of the commonest severe monogenic disorders in the world, due to the inheritance of two abnormal haemoglobin (beta globin) genes. SCD can cause severe pain, significant end-organ damage, pulmonary complications, and premature death. Silent cerebral infarcts are the commonest neurological complication in children and probably adults with SCD. Silent cerebral infarcts also affect academic performance, increase cognitive deficits and may lower intelligence quotient. OBJECTIVES: To assess the effectiveness of interventions to reduce or prevent silent cerebral infarcts in people with SCD. SEARCH METHODS: We searched for relevant trials in the Cochrane Library, MEDLINE (from 1946), Embase (from 1974), the Transfusion Evidence Library (from 1980), and ongoing trial databases; all searches current to 14 November 2019. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register: 07 October 2019. SELECTION CRITERIA: Randomised controlled trials comparing interventions to prevent silent cerebral infarcts in people with SCD. There were no restrictions by outcomes examined, language or publication status. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodological procedures. MAIN RESULTS: We included five trials (660 children or adolescents) published between 1998 and 2016. Four of the five trials were terminated early. The vast majority of participants had the haemoglobin (Hb)SS form of SCD. One trial focused on preventing silent cerebral infarcts or stroke; three trials were for primary stroke prevention and one trial dealt with secondary stroke prevention. Three trials compared the use of regular long-term red blood cell transfusions to standard care. Two of these trials included children with no previous long-term transfusions: one in children with normal transcranial doppler (TCD) velocities; and one in children with abnormal TCD velocities. The third trial included children and adolescents on long-term transfusion. Two trials compared the drug hydroxyurea and phlebotomy to long-term transfusions and iron chelation therapy: one in primary prevention (children), and one in secondary prevention (children and adolescents). The quality of the evidence was moderate to very low across different outcomes according to GRADE methodology. This was due to trials being at high risk of bias because they were unblinded; indirectness (available evidence was only for children with HbSS); and imprecise outcome estimates. Long-term red blood cell transfusions versus standard care Children with no previous long-term transfusions and higher risk of stroke (abnormal TCD velocities or previous history of silent cerebral infarcts) Long-term red blood cell transfusions may reduce the incidence of silent cerebral infarcts in children with abnormal TCD velocities, risk ratio (RR) 0.11 (95% confidence interval (CI) 0.02 to 0.86) (one trial, 124 participants, low-quality evidence); but make little or no difference to the incidence of silent cerebral infarcts in children with previous silent cerebral infarcts on magnetic resonance imaging and normal or conditional TCDs, RR 0.70 (95% CI 0.23 to 2.13) (one trial, 196 participants, low-quality evidence). No deaths were reported in either trial. Long-term red blood cell transfusions may reduce the incidence of: acute chest syndrome, RR 0.24 (95% CI 0.12 to 0.49) (two trials, 326 participants, low-quality evidence); and painful crisis, RR 0.63 (95% CI 0.42 to 0.95) (two trials, 326 participants, low-quality evidence); and probably reduces the incidence of clinical stroke, RR 0.12 (95% CI 0.03 to 0.49) (two trials, 326 participants, moderate-quality evidence). Long-term red blood cell transfusions may improve quality of life in children with previous silent cerebral infarcts (difference estimate -0.54; 95% confidence interval -0.92 to -0.17; one trial; 166 participants), but may have no effect on cognitive function (least squares means: 1.7, 95% CI -1.1 to 4.4) (one trial, 166 participants, low-quality evidence). Transfusions continued versus transfusions halted: children and adolescents with normalised TCD velocities (79 participants; one trial) Continuing red blood cell transfusions may reduce the incidence of silent cerebral infarcts, RR 0.29 (95% CI 0.09 to 0.97 (low-quality evidence). We are very uncertain whether continuing red blood cell transfusions has any effect on all-cause mortality, Peto odds ratio (OR) 8.00 (95% CI 0.16 to 404.12); or clinical stroke, RR 0.22 (95% CI 0.01 to 4.35) (very low-quality evidence). The trial did not report: comparative numbers for SCD-related adverse events; quality of life; or cognitive function. Hydroxyurea and phlebotomy versus transfusions and chelation Primary prevention, children (121 participants; one trial) We are very uncertain whether switching to hydroxyurea and phlebotomy has any effect on: silent cerebral infarcts (no infarcts); all-cause mortality (no deaths); risk of stroke (no strokes); or SCD-related complications, RR 1.52 (95% CI 0.58 to 4.02) (very low-quality evidence). Secondary prevention, children and adolescents with a history of stroke (133 participants; one trial) We are very uncertain whether switching to hydroxyurea and phlebotomy has any effect on: silent cerebral infarcts, Peto OR 7.28 (95% CI 0.14 to 366.91); all-cause mortality, Peto OR 1.02 (95%CI 0.06 to 16.41); or clinical stroke, RR 14.78 (95% CI 0.86 to 253.66) (very low-quality evidence). Switching to hydroxyurea and phlebotomy may increase the risk of SCD-related complications, RR 3.10 (95% CI 1.42 to 6.75) (low-quality evidence). Neither trial reported on quality of life or cognitive function. AUTHORS' CONCLUSIONS: We identified no trials for preventing silent cerebral infarcts in adults, or in children who do not have HbSS SCD. Long-term red blood cell transfusions may reduce the incidence of silent cerebral infarcts in children with abnormal TCD velocities, but may have little or no effect on children with normal TCD velocities. In children who are at higher risk of stroke and have not had previous long-term transfusions, long-term red blood cell transfusions probably reduce the risk of stroke, and other SCD-related complications (acute chest syndrome and painful crises). In children and adolescents at high risk of stroke whose TCD velocities have normalised, continuing red blood cell transfusions may reduce the risk of silent cerebral infarcts. No treatment duration threshold has been established for stopping transfusions. Switching to hydroxyurea with phlebotomy may increase the risk of silent cerebral infarcts and SCD-related serious adverse events in secondary stroke prevention. All other evidence in this review is of very low-quality.


Assuntos
Anemia Falciforme/complicações , Antidrepanocíticos/uso terapêutico , Infarto Encefálico/prevenção & controle , Transfusão de Eritrócitos , Hidroxiureia/uso terapêutico , Flebotomia , Adolescente , Anemia Falciforme/tratamento farmacológico , Antidrepanocíticos/efeitos adversos , Infarto Encefálico/etiologia , Causas de Morte , Criança , Cognição/fisiologia , Humanos , Hidroxiureia/efeitos adversos , Flebotomia/efeitos adversos , Prevenção Primária/métodos , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Prevenção Secundária/métodos , Acidente Vascular Cerebral/prevenção & controle
18.
AJNR Am J Neuroradiol ; 41(3): 501-507, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32115417

RESUMO

BACKGROUND AND PURPOSE: The natural history and optimal treatment of extracranial carotid artery aneurysms are unknown. Gadolinium enhancement of the aneurysm wall may reflect aneurysm wall inflammation and instability. In this study, we investigated the feasibility of extracranial carotid artery aneurysm wall imaging and explored a potential relationship of aneurysm wall enhancement with aneurysm growth and the presence of (silent) brain infarcts and white matter lesions. MATERIALS AND METHODS: Fourteen conservatively treated patients with 15 asymptomatic extracranial carotid artery aneurysms underwent gadolinium-enhanced 3T MR imaging at 2 time points with a 12-month interval. Primary outcome was growth of the aneurysm sac (≥2.0 mm); secondary outcomes were the presence of (silent) brain infarcts and white matter lesions at baseline and follow-up. MR images were reviewed by 2 independent observers, and inter- and intraobserver reproducibility was assessed. RESULTS: Seven (50%) patients were men; the median age was 55 years (range, 40-69 years). Eleven extracranial carotid artery aneurysms (73%) were saccular (median size, 11 mm; range, 5.0-38.5 mm), and 4 were fusiform (median size, 21.5 mm; range, 10.0-40.0 mm). Eleven of 15 aneurysms (73%) exhibited gadolinium enhancement at baseline. Four aneurysms (27%) showed growth at follow-up imaging, 2 gadolinium-positive (+) and 2 gadolinium-negative (-) (P = .245). Three patients (21%) had ipsilateral brain infarcts at baseline; 1 of them showed a new silent brain infarct at follow-up imaging (gadolinium+). Nine patients (64%) showed bilateral white matter lesions at baseline. In 3 patients, increased white matter lesion severity was observed at follow-up (2 gadolinium+). All observations showed excellent inter- and intraobserver reproducibility. CONCLUSIONS: In this explorative study, we demonstrated that extracranial carotid artery aneurysm wall imaging was feasible. Future well-powered studies are needed to investigate whether extracranial carotid artery aneurysm gadolinium enhancement predicts aneurysm growth and thromboembolic complications.


Assuntos
Aneurisma/diagnóstico por imagem , Doenças das Artérias Carótidas/diagnóstico por imagem , Imagem por Ressonância Magnética/métodos , Adulto , Idoso , Aneurisma/complicações , Infarto Encefálico/diagnóstico por imagem , Infarto Encefálico/etiologia , Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/complicações , Meios de Contraste , Feminino , Gadolínio , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes
19.
J Trauma Acute Care Surg ; 88(6): 796-802, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32176175

RESUMO

BACKGROUND: Patients with blunt cerebrovascular injuries are at risk of thromboembolic stroke. Although primary prevention with antithrombotic therapy is widely used in this setting, its effectiveness is not well defined and requires further investigation. The aim of this study was to evaluate the utility of magnetic resonance imaging (MRI)-detected ischemic brain lesions as a possible future outcome for randomized clinical trials in this patient population. METHODS: This prospective observational study included 20 adult blunt trauma patients admitted to a level I trauma center with a screening neck CTA showing extracranial carotid or vertebral artery injury. All subjects lacked initial evidence of an ischemic stroke and were managed with antithrombotic therapy and observation and then underwent brain MRI within 30 days of the injury to assess for ischemic lesions. The MRI scans included diffusion, susceptibility, and Fluid-attenuated Inversion Recovery (FLAIR) sequences, and were reviewed by two neuroradiologists blinded to the computed tomography angiography (CTA) findings. RESULTS: Eleven CTAs were done in the emergency department upon admission. There were 12 carotid artery dissections and 11 unilateral or bilateral vertebral artery injuries. Median interval between injury and MRI scan was 4 days (range, 0.1-14; interquartile range, 3-7 days). Diffusion-weighted imaging evidence of new ischemic lesions was present in 10 (43%) of 23 of the injured artery territories. In those injuries with ischemic lesions, the median number was 8 (range, 2-25; interquartile range, 5-8). None of the lesions were symptomatic. Blunt cerebrovascular injury was associated with a higher mean ischemic lesion count (mean count of 3.17 vs. 0.14, p < 0.0001), with the association remaining after adjusting for injury severity score (p < 0.0001). CONCLUSION: In asymptomatic blunt trauma patients with CTA evidence of extracranial cerebrovascular injury and treated with antithrombotic therapy, nearly half of arterial injuries are associated with ischemic lesions on MRI. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.


Assuntos
Infarto Encefálico/epidemiologia , Traumatismo Cerebrovascular/epidemiologia , Traumatismos Cranianos Fechados/complicações , Imagem por Ressonância Magnética/estatística & dados numéricos , Tromboembolia/prevenção & controle , Adulto , Doenças Assintomáticas/terapia , Infarto Encefálico/diagnóstico por imagem , Infarto Encefálico/etiologia , Artérias Carótidas/diagnóstico por imagem , Angiografia Cerebral/estatística & dados numéricos , Traumatismo Cerebrovascular/diagnóstico por imagem , Traumatismo Cerebrovascular/etiologia , Angiografia por Tomografia Computadorizada/estatística & dados numéricos , Feminino , Fibrinolíticos/administração & dosagem , Traumatismos Cranianos Fechados/diagnóstico por imagem , Traumatismos Cranianos Fechados/tratamento farmacológico , Humanos , Masculino , Pessoa de Meia-Idade , Pescoço/irrigação sanguínea , Pescoço/diagnóstico por imagem , Estudos Prospectivos , Tromboembolia/etiologia , Centros de Traumatologia/estatística & dados numéricos , Artéria Vertebral/diagnóstico por imagem
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