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1.
Neurology ; 102(10): e209324, 2024 May 28.
Artigo em Inglês | MEDLINE | ID: mdl-38709999

RESUMO

BACKGROUND AND OBJECTIVES: There is uncertainty whether patients with large vessel occlusion (LVO) presenting in the late 6-hour to 24-hour time window can be selected for endovascular therapy (EVT) by noncontrast CT (NCCT) and CT angiography (CTA) for LVO detection. We evaluated the clinical outcomes of patients selected for EVT by NCCT compared with those medically managed in the extended time window. METHODS: This multinational cohort study was conducted at 66 sites across 10 countries. Consecutive patients with proximal anterior LVO stroke selected for EVT by NCCT or medically managed and presenting within 6-24 hours of time last seen well (TSLW) from January 2014 to May 2022 were included. The primary end point was the 90-day ordinal shift in the modified Rankin Scale (mRS) score. Inverse probability treatment weighting (IPTW) and multivariable methods were used. RESULTS: Of 5,098 patients screened, 839 patients were included, with a median (interquartile range) age of 75 (64-83) years; 455 (54.2%) were women. There were 616 patients selected to undergo EVT by NCCT (73.4%) and 223 (26.6%) who were medically managed. In IPTW analyses, there was a more favorable 90-day ordinal mRS shift in patients selected by NCCT to EVT vs those who were medically managed (odds ratio [OR] 1.99, 95% CI 1.53-2.59; p < 0.001). There were higher rates of 90-day functional independence (mRS 0-2) in the EVT group (40.1% vs 18.4%, OR 3.31, 95% CI 2.11-5.20; p < 0.001). sICH was nonsignificantly higher in the EVT group (8.5% vs 1.4%, OR 3.77, 95% CI 0.72-19.7, p = 0.12). Mortality at 90 days was lower in the EVT vs MM group (23.9% vs 32.3%, OR 0.61, 95% CI 0.45-0.83, p = 0.002). DISCUSSION: In patients with proximal anterior LVO in the extended time window, there was a lower rate of disability and mortality in patients selected with NCCT and CTA to EVT compared with those who were medically managed. These findings support the use of NCCT as a simpler and more inclusive approach to patient selection in the extended window. TRIAL REGISTRATION INFORMATION: This study was registered at ClinicalTrials.gov under NCT04096248. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that for patients with proximal anterior circulation occlusion presenting with ischemic stroke from 6 to 24 hours, compared with medical management, those undergoing thrombectomy based on NCCT have reduced disability and mortality at 90 days.


Assuntos
Procedimentos Endovasculares , Trombectomia , Humanos , Feminino , Idoso , Masculino , Trombectomia/métodos , Idoso de 80 Anos ou mais , Pessoa de Meia-Idade , Procedimentos Endovasculares/métodos , Angiografia por Tomografia Computadorizada , Tomografia Computadorizada por Raios X , Estudos de Coortes , Tempo para o Tratamento , Resultado do Tratamento , Angiografia Cerebral
2.
J Clin Neurosci ; 124: 109-114, 2024 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-38696975

RESUMO

INTRODUCTION: The prevalence of intracranial aneurysms (IA) in patients with acute ischemic stroke (AIS) requiring mechanical thrombectomy (MT) is unclear. OBJECTIVE: To describe the prevalence of IA in patients with AIS and their influence on MT. MATERIALS & METHODS: This is a retrospective cohort study on all patients admitted with a diagnosis of AIS from January 2008 to March 2022 at a tertiary academic center. The records were reviewed for demographic, clinical, imaging, and outcomes data. Only patients who had CTA at admission were included in this analysis. RESULTS: Among 2265 patients admitted with AIS, this diagnosis was confirmed in 2113 patients (93.3 %). We included 1111 patients (52.6 %) who had head CTA and 321 (28.9 %) who underwent MT. The observed prevalence of aneurysms on CTA was 4.5 % (50/1111 patients), and 8 (16 %) had multiple aneurysms. MT was performed in 7 patients harboring IAs: 6 ipsilateral (5 proximal and 1 distal to the occlusion)and 1 contralateral aneurysm.. The patient with a contralateral aneurysm had a TICI 2B score In patients with ipsilateral aneurysms, TICI 2B or 3 was achieved in 3 cases (50 %), which is significantly lower than historical control of MT (91.6 %) without IA (p = 0.01). No aneurysms ruptured during MT. The aneurysm noted distal to the occlusion was mycotic. CONCLUSION: In this analysis, the observed prevalence of IA in patients with AIS was 4.5%. Ipsilateral aneurysms (proximal or distal to the occlusion site) deserve particular attention, given the potential risk of rupture during MT. Aneurysms located distal to the occlusion were mycotic and the rate of recanization in patients with ipsilateral aneurysms was low compared to historical controls. Further studies are needed to improve the outcomes in patients with IA requiring MT.


Assuntos
Aneurisma Intracraniano , AVC Isquêmico , Centros de Atenção Terciária , Trombectomia , Humanos , Aneurisma Intracraniano/epidemiologia , Aneurisma Intracraniano/cirurgia , Aneurisma Intracraniano/complicações , Masculino , Feminino , AVC Isquêmico/epidemiologia , AVC Isquêmico/cirurgia , Estudos Retrospectivos , Pessoa de Meia-Idade , Idoso , Prevalência , Trombectomia/métodos , Idoso de 80 Anos ou mais
3.
N Engl J Med ; 390(18): 1677-1689, 2024 May 09.
Artigo em Inglês | MEDLINE | ID: mdl-38718358

RESUMO

BACKGROUND: The use of thrombectomy in patients with acute stroke and a large infarct of unrestricted size has not been well studied. METHODS: We assigned, in a 1:1 ratio, patients with proximal cerebral vessel occlusion in the anterior circulation and a large infarct (as defined by an Alberta Stroke Program Early Computed Tomographic Score of ≤5; values range from 0 to 10) detected on magnetic resonance imaging or computed tomography within 6.5 hours after symptom onset to undergo endovascular thrombectomy and receive medical care (thrombectomy group) or to receive medical care alone (control group). The primary outcome was the score on the modified Rankin scale at 90 days (scores range from 0 to 6, with higher scores indicating greater disability). The primary safety outcome was death from any cause at 90 days, and an ancillary safety outcome was symptomatic intracerebral hemorrhage. RESULTS: A total of 333 patients were assigned to either the thrombectomy group (166 patients) or the control group (167 patients); 9 were excluded from the analysis because of consent withdrawal or legal reasons. The trial was stopped early because results of similar trials favored thrombectomy. Approximately 35% of the patients received thrombolysis therapy. The median modified Rankin scale score at 90 days was 4 in the thrombectomy group and 6 in the control group (generalized odds ratio, 1.63; 95% confidence interval [CI], 1.29 to 2.06; P<0.001). Death from any cause at 90 days occurred in 36.1% of the patients in the thrombectomy group and in 55.5% of those in the control group (adjusted relative risk, 0.65; 95% CI, 0.50 to 0.84), and the percentage of patients with symptomatic intracerebral hemorrhage was 9.6% and 5.7%, respectively (adjusted relative risk, 1.73; 95% CI, 0.78 to 4.68). Eleven procedure-related complications occurred in the thrombectomy group. CONCLUSIONS: In patients with acute stroke and a large infarct of unrestricted size, thrombectomy plus medical care resulted in better functional outcomes and lower mortality than medical care alone but led to a higher incidence of symptomatic intracerebral hemorrhage. (Funded by Montpellier University Hospital; LASTE ClinicalTrials.gov number, NCT03811769.).


Assuntos
Infarto da Artéria Cerebral Anterior , Acidente Vascular Cerebral , Trombectomia , Terapia Trombolítica , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Hemorragia Cerebral/etiologia , Terapia Combinada , Procedimentos Endovasculares , Imageamento por Ressonância Magnética , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/terapia , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/métodos , Tomografia Computadorizada por Raios X , Infarto Encefálico/diagnóstico por imagem , Infarto Encefálico/etiologia , Infarto Encefálico/terapia , Doença Aguda , Artérias Cerebrais/diagnóstico por imagem , Artérias Cerebrais/cirurgia , Doenças Arteriais Cerebrais/complicações , Doenças Arteriais Cerebrais/diagnóstico por imagem , Doenças Arteriais Cerebrais/patologia , Doenças Arteriais Cerebrais/cirurgia , Infarto da Artéria Cerebral Anterior/diagnóstico por imagem , Infarto da Artéria Cerebral Anterior/patologia , Infarto da Artéria Cerebral Anterior/cirurgia
4.
Am Heart J ; 272: 109-112, 2024 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-38705637

RESUMO

Data comparing catheter-based thrombectomy (CBT) and catheter-directed thrombolysis (CDT) in acute pulmonary embolism are lacking. To address this, we performed a meta-analysis of prospective and retrospective studies of CBT and compared it to performance goal rates of mortality and major bleeding from a recently published network meta-analysis. When compared with performance goal for CDT based on historical studies, CBT was noninferior for all-cause mortality (6.0% vs 6.87%; P-valueNI < .001), non-inferior and superior for major bleeding (4.9% vs 11%; P-valueNI < .001 and P < .001 for superiority).


Assuntos
Embolia Pulmonar , Trombectomia , Terapia Trombolítica , Humanos , Embolia Pulmonar/terapia , Trombectomia/métodos , Terapia Trombolítica/métodos , Doença Aguda , Resultado do Tratamento , Fibrinolíticos/administração & dosagem , Fibrinolíticos/uso terapêutico
5.
Medicine (Baltimore) ; 103(19): e37889, 2024 May 10.
Artigo em Inglês | MEDLINE | ID: mdl-38728483

RESUMO

RATIONALE: Anesthesia management of patients with dilated cardiomyopathy (DCM) has always been a challenge for anesthesiologists. Eighty percent of patients with DCM have heart failure as the first symptom, which may be accompanied by arrhythmias, thromboembolism, etc. Thrombosis is a significant contributing factor to adverse cardiovascular and cerebrovascular events, and its risk is severely underestimated in the anesthetic management of DCM. PATIENT CONCERNS: We present a case of a 54-year-old hypersensitive female patient with dilated cardiomyopathy and purpura who underwent an interventional thrombectomy under general anesthesia following a lower limb thromboembolism. DIAGNOSIS: Patient underwent an interventional thrombectomy under general anesthesia, with in situ thrombosis occurring during the surgery. INTERVENTIONS: After maintaining stable hemodynamics, proceed with the intervention to retrieve the embolus. OUTCOME: Patients in the advanced DCM developed acute thrombosis twice during embolization. LESSONS: This case discusses the causes of intraoperative thrombosis and summarizes and reflects on the anesthesia management of this case, which has always been one of the difficult points for anesthesiologists to master. In the anesthesia management of DCM patients, it is also necessary to maintain hemodynamic stability, enhance perioperative coagulation management, use anticoagulants rationally, and avoid the occurrence of thrombotic events.


Assuntos
Anestesia Geral , Cardiomiopatia Dilatada , Artéria Femoral , Trombectomia , Humanos , Feminino , Pessoa de Meia-Idade , Cardiomiopatia Dilatada/complicações , Cardiomiopatia Dilatada/cirurgia , Trombectomia/métodos , Artéria Femoral/cirurgia , Anestesia Geral/métodos , Tromboembolia/etiologia
6.
Sci Rep ; 14(1): 10024, 2024 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-38693311

RESUMO

Patients with stroke may develop hyperperfusion after a successful endovascular thrombectomy (EVT). However, the relationship between post-EVT hyperperfusion and clinical outcomes remains unclear and requires further clarification. We reviewed consecutive patients with anterior circulation occlusion who were successfully recanalized with EVT. Based on post-EVT arterial spin-labeling images, hyperperfusion was categorized as follows: global hyperperfusion (GHP), increased cerebral blood flow (CBF) in ≥ 50% of the culprit vessel territory; focal hyperperfusion (FHP), increased CBF in < 50% of the culprit vessel territory; no hyperperfusion (NHP), no discernible CBF increase. Factors associated with hyperperfusion were assessed, and clinical outcomes were compared among patients under different hyperperfusion categories. Among 131 patients, 25 and 40 patients developed GHP and FHP, respectively. Compared to other groups, the GHP group had worse National Institutes of Health Stroke Scale score (GHP vs. NHP/FHP, 18.1 ± 7.4 vs. 12.3 ± 6.0; p < 0.001), a larger post-EVT infarct volume (98.9 [42.3-132.7] vs. 13.5 [5.0-34.1] mL; p < 0.001), and a worse 90-day outcome (modified Rankin Scale, 3 [1-4] vs. 2 [0-3]; p = 0.030). GHP was independently associated with infarct volume (B = 0.532, standard error = 0.163, p = 0.001), and infarct volume was a major mediator of the association of GHP with unfavorable outcomes (total effect: ß = 0.176, p = 0.034; direct effect: ß = 0.045, p = 0.64; indirect effect: ß = 0.132, p = 0.017). Patients presenting with post-EVT GHP had poorer neurological prognosis, which is likely mediated by a large infarct volume.


Assuntos
Circulação Cerebrovascular , Procedimentos Endovasculares , AVC Isquêmico , Trombectomia , Humanos , Trombectomia/métodos , Trombectomia/efeitos adversos , Masculino , Feminino , Idoso , AVC Isquêmico/cirurgia , Procedimentos Endovasculares/métodos , Pessoa de Meia-Idade , Resultado do Tratamento , Idoso de 80 Anos ou mais , Estudos Retrospectivos
7.
J Neurol Sci ; 460: 122999, 2024 May 15.
Artigo em Inglês | MEDLINE | ID: mdl-38705135

RESUMO

BACKGROUND AND OBJECTIVE: Whether intracranial hemorrhage (ICH) detected using magnetic resonance imaging (MRI) affects the clinical outcomes of patients with large-vessel occlusion (LVO) treated with mechanical thrombectomy (MT) remains unclear. This study investigated the clinical features of ICH after MT detected solely by MRI. METHODS: This was a retrospective analysis of patients with acute ischemic stroke and occlusion of the internal carotid artery or middle cerebral artery treated with MT between April 2011 and March 2021. Among 632 patients, patients diagnosed with no ICH using CT, with a pre-morbid modified Rankin Scale (mRS) score ≤ 2, and those who underwent MRI including T2* and computed tomography (CT) within 72 h from MT were enrolled. The main outcomes were the association between ICH detected solely by MRI and clinical outcomes at 90 days. Poor clinical outcomes were defined as mRS score > 2 at 90 days after onset. RESULTS: Of the 246 patients, 29 (12%) had ICH on MRI (MRI-ICH(+)), and 217 (88%) were MRI-ICH(-). There was no significant difference between number of patients with MRI-ICH(+) experiencing poor (10 [12%]) and favorable (19 [12%]) outcomes. The mRS score at 90 days between patients with MRI-ICH (+) and MRI-ICH(-) was not significantly different (2 [1-4] vs. 2 [1-4], respectively). Higher age and lower ASPECTS were independent risk factors for poor outcomes, as shown by multivariate regression analysis. MRI-ICH(+) status was not associated with poor outcomes. CONCLUSIONS: ICH detected by MRI alone did not influence clinical outcomes in patients with LVO treated with MT.


Assuntos
Hemorragias Intracranianas , Imageamento por Ressonância Magnética , Trombectomia , Tomografia Computadorizada por Raios X , Humanos , Masculino , Feminino , Idoso , Estudos Retrospectivos , Trombectomia/métodos , Trombectomia/efeitos adversos , Hemorragias Intracranianas/diagnóstico por imagem , Hemorragias Intracranianas/etiologia , Pessoa de Meia-Idade , AVC Isquêmico/diagnóstico por imagem , Idoso de 80 Anos ou mais , Resultado do Tratamento , Relevância Clínica
8.
BMC Neurol ; 24(1): 155, 2024 May 07.
Artigo em Inglês | MEDLINE | ID: mdl-38714927

RESUMO

BACKGROUND: Chronic lung and heart diseases are more likely to lead an intensive end point after stroke onset. We aimed to investigate characteristics and outcomes of endovascular thrombectomy (EVT) in patients with acute large vessel occlusion stroke (ALVOS) and identify the role of comorbid chronic cardiopulmonary diseases in ALVOS pathogenesis. METHODS: In this single-center retrospective study, 191 consecutive patients who underwent EVT due to large vessel occlusion stroke in neurological intensive care unit were included. The chronic cardiopulmonary comorbidities and several conventional stroke risk factors were assessed. The primary efficacy outcome was functional independence (defined as a mRS of 0 to 2) at day 90. The primary safety outcomes were death within 90 days and the occurrence of symptomatic intracranial hemorrhage(sICH). Univariate analysis was applied to evaluate the relationship between factors and clinical outcomes, and logistic regression model were developed to predict the prognosis of ALVOS. RESULTS: Endovascular therapy in ALVOS patients with chronic cardiopulmonary diseases, as compared with those without comorbidity, was associated with an unfavorable shift in the NHISS 24 h after EVT [8(4,15.25) versus 12(7.5,18.5), P = 0.005] and the lower percentage of patients who were functionally independent at 90 days, defined as a score on the modified Rankin scale of 0 to 2 (51.6% versus 25.4%, P = 0.000). There was no significant between-group difference in the frequency of mortality (12.1% versus 14.9%, P = 0.580) and symptomatic intracranial hemorrhage (13.7% versus 19.4%, P = 0.302) or of serious adverse events. Moreover, a prediction model showed that existence of cardiopulmonary comorbidities (OR = 0.456, 95%CI 0.209 to 0.992, P = 0.048) was independently associated with functional independence at day 90. CONCLUSIONS: EVT was safe in ALVOS patients with chronic cardiopulmonary diseases, whereas the unfavorable outcomes were achieved in such patients. Moreover, cardiopulmonary comorbidity had certain clinical predictive value for worse stroke prognosis.


Assuntos
Comorbidade , Procedimentos Endovasculares , Trombectomia , Humanos , Masculino , Feminino , Idoso , Estudos Retrospectivos , Pessoa de Meia-Idade , Procedimentos Endovasculares/métodos , Trombectomia/métodos , Trombectomia/estatística & dados numéricos , Trombectomia/efeitos adversos , Cardiopatias/epidemiologia , Cardiopatias/complicações , Cardiopatias/cirurgia , Idoso de 80 Anos ou mais , Estudos de Coortes , Pneumopatias/epidemiologia , Pneumopatias/cirurgia , Resultado do Tratamento , AVC Isquêmico/cirurgia , AVC Isquêmico/epidemiologia , Acidente Vascular Cerebral/cirurgia , Acidente Vascular Cerebral/epidemiologia
9.
Dtsch Med Wochenschr ; 149(12): 679-683, 2024 Jun.
Artigo em Alemão | MEDLINE | ID: mdl-38781990

RESUMO

Several catheter-based systems have been developed for interventional recanalization of pulmonary embolism. These include local ultrasound assisted thrombolysis (EKOS), in-toto-thrombectomy via retriever and aspiration system (FlowTriever) and the Indigo mechanical aspiration system. Safety and efficacy in the removal of thrombus have been demonstrated for all systems. Interventional recanalization strategies for high- and intermediate-high risk pulmonary embolism are potentially more effective in the removal of thrombus and restoration of right heart function than systemic thrombolysis with a lower risk of major bleeding complications. Preliminary data from registries and observational studies are very promising whereas the evidence for systemic thrombolysis treatment in high and intermediate-high risk pulmonary embolism is low. Randomized controlled clinical trials are currently performed comparing catheter based interventional therapies to systemic thrombolysis for the treatment of intermediate-high risk pulmonary embolisms. Primary outcome measurements include mortality, hemodynamic collapse, and major bleedings. Results are expected in 2025. The introduction of interventional therapies for pulmonary embolism was accompanied by an increased awareness of the complexity of pulmonary embolism management. The need for specialized interdisciplinary pulmonary embolism response teams (PERT-teams) and a well-structured approach including a PDCA cycle was recognized.


Assuntos
Embolia Pulmonar , Trombectomia , Terapia Trombolítica , Embolia Pulmonar/terapia , Humanos
10.
BMC Neurol ; 24(1): 164, 2024 May 21.
Artigo em Inglês | MEDLINE | ID: mdl-38773425

RESUMO

BACKGROUND AND PURPOSE: The relationship between heart rate and the prognosis of patients with large vessel occlusion strokes treated with mechanical thrombectomy (MT) is not well established. This study aimed to evaluate the association of mean heart rate and heart rate variability (HRV) with the clinical outcomes after MT therapy. METHODS: Acute ischemic stroke patients undergoing MT therapy were prospectively recruited from March 2020 to November 2022. Their heart rate was collected every hour for the initial 72 h after MT procedure, and the variability of heart rate was measured by standard deviation (SD) and coefficient of variation (CV). All-cause mortality and worsening of functional outcome (change in modified Rankin Scale (mRS) score) at 3-month were captured. Binary logistic regression was used to evaluate the association between heart rate indicators and all-cause mortality. Ordinal logistic regression was used to evaluate the association between heart rate indicators and worsening of functional outcome. RESULTS: Among 191 MT-treated patients, 51(26.7%) patients died at 3-month after stroke. Increased mean heart rate per 10-bpm, heart rate SD and CV per 5-unit were all associated with the increased risk of mortality (adjusted hazard ratio [aHR] with 95% CI: 1.29 [1.09-1.51], 1.19 [1.07-1.32], 1.14 [1.03-1.27]; respectively). Patients in the highest tertile of heart rate SD had an increased risk of mortality (4.62, 1.70-12.52). After using mRS as a continuous variable, we found increased mean heart rate per 10-bpm, heart rate SD and CV per 5-unit were associated with the worsening of functional outcome (adjusted odds ratio [aOR] with 95% CI: 1.35 [1.11-1.64], 1.27 [1.05-1.53], 1.19 [1.02-1.40]; respectively). A linear relationship was observed between mean heart rate or heart rate SD and mortality; while all of the heart rate measures in this study showed a linear relationship with the worsening of functional outcome. CONCLUSIONS: Higher mean heart rate and HRV were associated with the increased risk of 3-month all-cause mortality and worse functional outcome after MT therapy for AIS patients.


Assuntos
Frequência Cardíaca , AVC Isquêmico , Trombectomia , Humanos , Masculino , Feminino , Idoso , Frequência Cardíaca/fisiologia , Pessoa de Meia-Idade , Trombectomia/métodos , Trombectomia/estatística & dados numéricos , AVC Isquêmico/mortalidade , AVC Isquêmico/cirurgia , AVC Isquêmico/terapia , AVC Isquêmico/fisiopatologia , Resultado do Tratamento , Idoso de 80 Anos ou mais , Estudos Prospectivos , Prognóstico , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/terapia , Acidente Vascular Cerebral/fisiopatologia
13.
J Physiol Pharmacol ; 75(2): 145-157, 2024 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-38736262

RESUMO

Stroke is the second leading cause of death worldwide. Understanding of gene expression dynamics could bring new approaches in diagnostics and therapy of stroke. Small noncoding molecules termed 'microRNA' represent the most flexible network of gene expression regulators. To screen out miRNAs that are mainly regulated during reperfusion in mechanically embolized patients, and study their mechanisms of action in reperfusion injury after thrombectomy, in order to find new therapeutic targets for mechanically embolized patients. Serums from 30 patients with moderate to severe stroke after mechanical thrombectomy (MT) were collected to measure miRNA expressions. Clinical information of patients was analyze, and patients were divided into poor prognosis and good prognosis. Factors affecting prognosis was classified, and independent risk factors for poor prognosis were determined. Prognostic value of National Institutes of Health Stroke Scale (NIHSS) score on admission to patients with MT was assessed. ROC (receiver operating characteristic) curves were drawn, and Kaplan-Merier method determined whether different NIHSS scores at admission had any difference in the in-hospital survival rate of consistency index/random consistency index (CI/RI) patients treated with MT. An oxygen-glucose deprivation/reperfusion (OGD/R) cell model and an middle cerebral artery occlusion (MCAO)/reperfusion mouse model were established, in which miR-298 expression was tested. In OGD/R cells, proliferation, apoptosis, and autophagy were assessed after intervention with miR-298 and/or autophagy related gene 5 (ATG5). In MCAO mice, the infarct area was calculated, and neurological function was assessed. The relationship between miR-298 and ATG5 was explored and validated. Age, diabetes, hypertension, hemorrhage transformation, NIHSS score at admission, leukocyte, neutrophil count and neutrophil to lymphocyte ratio (NLR) level were associated with patient's prognosis. Diabetes, NIHSS score at admission, and hemorrhagic transformation were independent risk factors for predicting poor prognosis in patients treated with MT. NIHSS score on admission had a predictive value on patient's prognosis. miR-298 was upregulated in acute cerebral ischemia patients with MT (p<0.05), especially in those with poor prognosis. miR-298 was elevated in both cell and mouse models (p<0.05). Apoptosis and autophagy of cells were weakened after miR-298 knockdown, and infarction in the mouse brain tissues was reduced. ATG5 was a target of miR-298. Overexpressing ATG5 rescued miR-298-induced apoptosis and autophagy. In conclusion: regulation of miR-298 and ATG5 attenuates neuronal apoptosis and autophagy, providing a new strategy for brain injury after reperfusion in patients with MT.


Assuntos
Apoptose , MicroRNAs , Traumatismo por Reperfusão , Trombectomia , MicroRNAs/genética , MicroRNAs/metabolismo , Animais , Humanos , Masculino , Idoso , Feminino , Pessoa de Meia-Idade , Trombectomia/métodos , Traumatismo por Reperfusão/metabolismo , Camundongos , Infarto da Artéria Cerebral Média/cirurgia , Infarto da Artéria Cerebral Média/metabolismo , Camundongos Endogâmicos C57BL , Autofagia/fisiologia , Prognóstico , Acidente Vascular Cerebral
14.
J Med Case Rep ; 18(1): 244, 2024 May 12.
Artigo em Inglês | MEDLINE | ID: mdl-38734655

RESUMO

BACKGROUND: Danon disease is a lysosomal storage disorder with X-linked inheritance. The classic triad is severe hypertrophic cardiomyopathy, myopathy, and intellectual disability, with different phenotypes between both genders. Ischemic stroke is an uncommon complication, mostly cardioembolic, related to intraventricular thrombus or atrial fibrillation, among others. CASE REPORT: We report the case of a 14-year-old Caucasian male patient with Danon disease who suffered from an acute ischemic stroke due to occlusion in the M1 segment of the middle cerebral artery. He underwent mechanical thrombectomy, resulting in successful revascularization with satisfactory clinical outcome. We objectified the intraventricular thrombus in the absence of arrhythmic events. CONCLUSION: To our knowledge, we report the first case of ischemic stroke related to Danon disease treated with endovascular treatment.


Assuntos
Doença de Depósito de Glicogênio Tipo IIb , Humanos , Masculino , Doença de Depósito de Glicogênio Tipo IIb/complicações , Adolescente , Procedimentos Endovasculares , AVC Isquêmico/cirurgia , AVC Isquêmico/diagnóstico por imagem , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Infarto da Artéria Cerebral Média/cirurgia , Resultado do Tratamento , Trombectomia
15.
Mo Med ; 121(2): 127-135, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38694595

RESUMO

The field of endovascular neurosurgery has experienced remarkable progress over the last few decades. Endovascular treatments have continued to gain traction as the advancement of technology, technique, and procedural safety has allowed for the expansion of treatment indications of various cerebrovascular pathologies. Interventions such as the coiling of intracranial aneurysms, carotid artery stenting, mechanical thrombectomy in the setting of ischemic stroke, and endovascular embolization of arteriovenous malformations have all seen transformations in their safety and efficacy, expanding the scope of endovascularly treatable conditions and offering new hope to patients who may have otherwise not been candidates for surgical intervention. Despite this notable progress, challenges persist, including complications associated with device deployment and questions regarding long-term outcomes. This article explores the advancements in endovascular neurosurgical techniques, highlighting the impact on patient care, outcomes, and the evolution of traditional surgical methods.


Assuntos
Transtornos Cerebrovasculares , Procedimentos Endovasculares , Stents , Humanos , Procedimentos Endovasculares/métodos , Procedimentos Endovasculares/tendências , Transtornos Cerebrovasculares/cirurgia , Transtornos Cerebrovasculares/terapia , Embolização Terapêutica/métodos , Aneurisma Intracraniano/cirurgia , Aneurisma Intracraniano/terapia , Trombectomia/métodos
16.
Neurology ; 102(10): e209270, 2024 May 28.
Artigo em Inglês | MEDLINE | ID: mdl-38739880

RESUMO

BACKGROUND AND OBJECTIVES: The effect of endovascular therapy (EVT) for large vessel occlusion stroke on cognitive outcomes is not well understood. We evaluated the effect of EVT on cognitive function in the Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times (ESCAPE) trial. METHODS: Patient data from the ESCAPE randomized trial were analyzed. Cognitive assessments completed at 90 days after stroke were the Montreal Cognitive Assessment (MoCA), the Sunnybrook Neglect Assessment Procedure (SNAP), the Boston Naming Test (BNT), Trail-making test A (Trails A), and Trail-making test B (Trails B). We used logistic regression to evaluate the association between EVT and favorable cognitive outcome on the 5 separate tests, adjusting for demographic and clinical factors. We used generalized estimating equations and ordinal regression to determine the odds of favorable outcome with EVT on global cognition incorporating the 5 tests. We added final infarct volume (FIV) to the models to assess the relationship of FIV with cognitive outcome. RESULTS: The ESCAPE trial included 315 patients, 165 randomized to EVT and 150 randomized to control. There was higher odds of favorable outcome with EVT for MoCA (adjusted odds ratio [aOR] 2.32, 95% CI 1.30-4.16), SNAP (aOR 3.85, 95% CI 2.00-7.45), BNT (aOR 2.33, 95% CI 1.30-4.17), trails A (aOR 3.50, 95% CI 1.93-6.36), and trails B (aOR 2.56, 95% CI 1.46-4.48). There was higher odds of favorable outcome with EVT on global binary (aOR 2.57, 95% CI 1.67-3.94) and ordinal analyses (aOR 2.83, 95% CI 1.68-4.76) of cognitive function. After adding FIV to the models, both FIV and EVT were significantly associated with cognitive outcome. There was a significant correlation between global cognitive performance and mRS at day 90 (r = -0.78, p < 0.001), with the largest reductions in favorable cognitive outcome from mRS score 4 to 5 and from mRS 2 to 3. DISCUSSION: In this secondary analysis of the ESCAPE trial, EVT was associated with favorable outcome on 5 separate cognitive tests and in global analyses of cognitive benefit. These results provide novel evidence for the effect of EVT on cognition and support the global benefit of treatment with EVT. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that in patients with acute ischemic stroke due to intracranial internal carotid artery (ICA) or M1 segment MCA occlusion, including tandem extracranial ICA occlusions, EVT compared with best medical therapy increased odds of favorable cognitive outcome.


Assuntos
Procedimentos Endovasculares , AVC Isquêmico , Trombectomia , Humanos , Masculino , Feminino , AVC Isquêmico/cirurgia , AVC Isquêmico/terapia , Procedimentos Endovasculares/métodos , Idoso , Trombectomia/métodos , Pessoa de Meia-Idade , Resultado do Tratamento , Cognição/fisiologia , Testes Neuropsicológicos , Idoso de 80 Anos ou mais
17.
Wounds ; 36(4): 115-118, 2024 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-38743856

RESUMO

BACKGROUND: DVT is associated with clinically significant sequelae, and the most widely used therapies for severe venous disease are often ineffective. Mechanical thrombectomy (MT) offers a promising approach, but most patients with a history of DVT are not evaluated for such intervention. OBJECTIVE: To present overall outcomes and the outcome of a single case after use of an MT procedure to manage advanced deep venous disease. MATERIALS AND METHODS: This retrospective, single-center analysis included all patients with a CEAP score of C6 secondary to DVT who were referred from a wound clinic and underwent an MT-based procedure. RESULTS: Eleven patients with 14 affected limbs were referred for treatment from an associated care network and were treated with MT. As necessary, adjunctive venoplasty and stent placement were also used. The endovascular treatment was successful in removing fibrous obstructions from veins and supporting the improvement or resolution of C6 venous disease in all cases, including the 66-year-old male discussed in the current report. CONCLUSION: Collaboration between endovascular interventionists and local postacute wound care specialists to identify and refer patients with severe venous disease for advanced treatment may lead to improved outcomes.


Assuntos
Encaminhamento e Consulta , Trombectomia , Trombose Venosa , Humanos , Masculino , Estudos Retrospectivos , Idoso , Feminino , Pessoa de Meia-Idade , Trombectomia/métodos , Trombose Venosa/terapia , Resultado do Tratamento , Adulto , Procedimentos Endovasculares/métodos
18.
Methodist Debakey Cardiovasc J ; 20(3): 13-18, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38765214

RESUMO

With a multitude of options for pulmonary embolism management, we review the most common diagnostic tools available for assessing risk as well as how each broad risk category is typically treated. Right heart dysfunction is the cornerstone for triage of these patients and should be the focus for decision-making, especially in challenging patients. We aim to provide a modern, clinical perspective for PE management in light of the multitude of intervention options.


Assuntos
Tomada de Decisão Clínica , Embolia Pulmonar , Embolia Pulmonar/terapia , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/fisiopatologia , Embolia Pulmonar/diagnóstico por imagem , Humanos , Fatores de Risco , Resultado do Tratamento , Medição de Risco , Valor Preditivo dos Testes , Terapia Trombolítica/efeitos adversos , Embolectomia , Procedimentos Endovasculares/efeitos adversos , Anticoagulantes/uso terapêutico , Anticoagulantes/efeitos adversos , Seleção de Pacientes , Trombectomia
19.
Methodist Debakey Cardiovasc J ; 20(3): 36-48, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38765215

RESUMO

Pulmonary embolism is a debilitating and potentially life-threatening disease characterized by high mortality and long-term adverse outcomes. Traditional treatment options are fraught with serious bleeding risks and incomplete thrombus removal, necessitating the development of innovative treatment strategies. While new interventional approaches offer promising potential for improved outcomes with fewer serious complications, their rapid development and need for more comparative clinical evidence makes it challenging for physicians to select the optimal treatment for each patient among the many options. This review summarizes the current published clinical data for both traditional treatments and more recent interventional approaches indicated for pulmonary embolism. While published studies thus far suggest that these newer interventional devices offer safe and effective options, more data is needed to understand their impact relative to the standard of care. The studies in progress that are anticipated to provide needed evidence are reviewed here since they will be critical for helping physicians make informed treatment choices and potentially driving necessary guideline changes.


Assuntos
Fibrinolíticos , Embolia Pulmonar , Trombectomia , Terapia Trombolítica , Humanos , Tomada de Decisão Clínica , Desenho de Equipamento , Fibrinolíticos/administração & dosagem , Fibrinolíticos/efeitos adversos , Embolia Pulmonar/terapia , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/mortalidade , Fatores de Risco , Trombectomia/efeitos adversos , Trombectomia/instrumentação , Terapia Trombolítica/efeitos adversos , Resultado do Tratamento
20.
Rev. neurol. (Ed. impr.) ; 78(9)1-15 may 2024. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-CR-367

RESUMO

Introducción El ictus isquémico agudo es una de las principales causas globales de morbimortalidad. La trombectomía mecánica ha mejorado el pronóstico funcional de esta patología; sin embargo, la transformación hemorrágica es una complicación frecuente. La tomografía computarizada (TC) de tecnología espectral, como prueba de neuroimagen de control, diferencia la extravasación de contraste de la transformación hemorrágica gracias al diferente comportamiento de los materiales a la energía dual, y esta distinción es de utilidad en su manejo clinicoterapéutico. Material y métodos. Estudio unicéntrico, observacional y retrospectivo, en el cual se investigó, mediante el acceso a una base de datos disociada y a la historia clínica, la presencia de una serie de variables clínicas, radiológicas y terapéuticas en los pacientes con ictus isquémico agudo que fueron tratados con trombectomía mecánica en nuestro hospital entre julio de 2022 y marzo de 2023.ResultadosDe los 155 pacientes incluidos, se realizó una TC craneal espectral en 63 y convencional en 75. En el grupo de TC espectral se detectaron 21 imágenes hiperdensas y en el grupo de TC convencional fueron 28. En el 42,8% de los casos en los que se detectó una hiperdensidad en el grupo de TC convencional no se pudo distinguir entre extravasación de contraste y transformación hemorrágica, en comparación con el 4,8% del grupo de TC espectral (p < 0,001).ConclusionesLa TC espectral confiere una gran confianza diagnóstica al radiólogo para establecer el tipo de hiperdensidad detectada y, por ello, proporciona también una gran confianza terapéutica al neurólogo para reiniciar precozmente la anticoagulación. (AU)


Introduction. Acute ischemic stroke is one of the leading global causes of morbidity and mortality. Mechanical thrombectomy has improved the functional prognosis of this condition; however, hemorrhagic transformation is a common complication. Spectral computed tomography (CT) imaging, as a neuroimaging control test, distinguishes contrast extravasation from hemorrhagic transformation due to the differential behavior of materials at dual energy levels. This distinction is valuable in its clinical therapeutic management.Material and methods. A single-center, observational, retrospective study was conducted in which the presence of various clinical, radiological, and therapeutic variables in patients with acute ischemic stroke treated with mechanical thrombectomy at our hospital between July 2022 and March 2023 was investigated using access to a dissociated database and medical records.Results. Out of 155 included patients, spectral cranial CT was performed in 63, and conventional cranial CT in 75. In the spectral CT group, 21 hyperdense images were detected, compared to 28 in the conventional CT group. In 42.8% of cases where hyperdensity was detected in the conventional CT group, it was not possible to distinguish between contrast extravasation and hemorrhagic transformation, in contrast to the 4.8% in the spectral CT group (p < 0.001).Conclusions. Spectral CT provides high diagnostic confidence to the radiologist in identifying the type of detected hyperdensity, thereby offering significant therapeutic confidence to the neurologist in early resuming anticoagulation therapy. (AU)


Assuntos
Humanos , Tomografia Computadorizada por Raios X , Trombectomia , Fibrilação Atrial
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