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Sakai K, Suda S, Iguchi Y, Abe A, Yagita Y, Kanzawa T, Okubo S, Fujimoto S, Kimura K. High pre-stroke CHADS 2 score predicts unfavorable functional outcome in acute cardioembolic stroke patients prescribed oral anticoagulant therapy: A sub-analysis of the PASTA registry study. J Stroke Cerebrovasc Dis 2024; 33:107519. [PMID: 38142567 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 11/24/2023] [Accepted: 11/27/2023] [Indexed: 12/26/2023] Open
Abstract
BACKGROUND AND PURPOSE The impact of CHADS2 score on outcome in patients with stroke taking an oral anticoagulant (OAC) has not yet been fully elucidated. We investigated the association between pre-stroke CHADS2 score and outcome at discharge in patients with acute cardioembolic (CE) stroke due to atrial fibrillation (AF) who were prescribed OAC. METHODS The data of 548 OAC-treated patients with AF and CE stroke who were registered in the multicenter Prospective Analysis of Stroke patients Taking oral Anticoagulants (PASTA) study were analyzed. High CHADS2 score was defined as a pre-stroke CHADS2 score ≥2. Unfavorable outcome was defined as a modified Rankin scale (mRS) of 3-6. The impacts of pre-stroke CHADS2 score on outcome at discharge were evaluated using multiple logistic regression analysis. RESULT A high CHADS2 score was found in 472/548 patients and unfavorable outcome was found in 330/548 patients. In patients with unfavorable outcome, age, male sex, pre-stroke CHADS2 score, initial National Institute Health Stroke Scale (NIHSS) score, and glucose level on admission were significantly higher, whereas creatinine clearance and body weight were significantly lower, than those with favorable outcome (each p < 0.001). Multivariate logistic regression analysis indicated that high CHADS2 score (OR 2.18, 95 %CI 1.08-4.42, p = 0.031), pre-stroke mRS (OR 2.21, 95 %CI 1.69-2.67, p < 0.001), and initial NIHSS score (OR 1.19, 95 %CI 1.17-1.24, p < 0.001) were independently associated with unfavorable outcome. CONCLUSION Pre-stroke CHADS2 score was associated with poor outcome in patients with cardioembolic stroke due to AF, even in those taking OAC.
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Affiliation(s)
- Kenichiro Sakai
- Department of Neurology, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo 105-0003, Japan.
| | - Satoshi Suda
- Department of Neurology, Nippon Medical School, Tokyo, Japan; Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Saitama, Japan
| | - Yasuyuki Iguchi
- Department of Neurology, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo 105-0003, Japan
| | - Arata Abe
- Department of Neurology and Stroke Medicine, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Yoshiki Yagita
- Department of Stroke Medicine, Kawasaki Medical School, Okayama, Japan
| | - Takao Kanzawa
- Department of Stroke Medicine, Institute of Brain and Blood Vessels, Mihara Memorial Hospital, Gunma, Japan and Institute of HM Network, Gunyukai Isesaki Clinic, Gunma, Japan
| | - Seiji Okubo
- Department of Cerebrovascular Medicine, NTT Medical Center Tokyo, Tokyo, Japan
| | - Shigeru Fujimoto
- Division of Neurology, Department of Medicine, Jichi Medical University Hospital, Tochigi, Japan
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
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Zhao H, Li C, Jin Z, Duan W, Shang L, Chang Y, Xu J, Ren J, Lin S, Wang Y, Zhu L, Wang G, Chen X, He C, Zheng M. Risk prediction of preoperative acute ischemic stroke in acute type A aortic dissection. Eur Radiol 2023; 33:7250-7259. [PMID: 37178204 DOI: 10.1007/s00330-023-09691-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/17/2023] [Accepted: 03/09/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVES To predict preoperative acute ischemic stroke (AIS) in acute type A aortic dissection (ATAAD). METHODS In this multi-center retrospective study, 508 consecutive patients diagnosed as ATAAD between April 2020 and March 2021 were considered for inclusion. The patients were divided into a development cohort and two validation cohorts based on time periods and centers. Clinical data and imaging findings obtained were analyzed. Univariable and multivariable logistic regression analyses were performed to identify predictors associated with preoperative AIS. The performance of resulting nomogram was evaluated in discrimination and calibration on all cohorts. RESULTS A total of 224 patients were in the development cohort, 94 in the temporal validation cohort, and 118 in the geographical validation cohort. Six predictors were identified: age, syncope, D-dimer, moderate to severe aortic valve insufficiency, diameter ratio of true lumen in ascending aorta < 0.33, and common carotid artery dissection. The nomogram established showed good discrimination (area under the receiver operating characteristic curve [AUC], 0.803; 95% CI: 0.742, 0.864) and calibration (Hosmer-Lemeshow test p = 0.300) in the development cohort. External validation showed good discrimination and calibration abilities in both temporal (AUC, 0.778; 95% CI: 0.671, 0.885; Hosmer-Lemeshow test p = 0.161) and geographical cohort (AUC, 0.806; 95% CI: 0.717, 0.895; Hosmer-Lemeshow test p = 0.100). CONCLUSIONS A nomogram, based on simple imaging and clinical variables collected on admission, showed good discrimination and calibration abilities in predicting preoperative AIS for ATAAD patients. KEY POINTS • A nomogram based on simple imaging and clinical findings may predict preoperative acute ischemic stroke in patients with acute type A aortic dissection in emergencies. • The nomogram showed good discrimination and calibration abilities in validation cohorts.
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Affiliation(s)
- Hongliang Zhao
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, 127 Changle West Road, Xi'an, China
| | - Chengxiang Li
- Department of Cardiovascular Surgery, Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, China
| | - Zhenxiao Jin
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military University, 127 Changle West Road, Xi'an, China.
| | - Weixun Duan
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military University, 127 Changle West Road, Xi'an, China
| | - Lei Shang
- Department of Health Statistics, Fourth Military Medical University, 127 Changle West Road, Xi'an, China
| | - Yingjuan Chang
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, 127 Changle West Road, Xi'an, China
| | - Jingji Xu
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, 127 Changle West Road, Xi'an, China
| | - Jialiang Ren
- GE Healthcare China, 2 Yongchang North Road, Beijing, China
| | - Shushen Lin
- Siemens Healthineers Ltd., 278 Zhou Zhugong Road, Shanghai, China
| | - Yan Wang
- Department of Radiology, People's Hospital of Xinjiang Uygur Autonomous Region, 91 Tianchi Road, Urumqi, China
| | - Li Zhu
- Department of Radiology, General Hospital of Ningxia Medical University, 804 Shengli Road, Yinchuan, China
| | - Gang Wang
- Department of Radiology, The First Hospital of Lanzhou University, 1 Donggang West Road, Lanzhou, China
| | - Xin Chen
- Department of Radiology, The Second Affiliated Hospital of Xi'an Jiaotong University, 157 Xiwu Road, Xi'an, China
| | - Chao He
- Department of Radiology, The Second Affiliated Hospital of Shaanxi University of Chinese Medicine, 5 Weiyang West Road, Xianyang, China
| | - Minwen Zheng
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, 127 Changle West Road, Xi'an, China.
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Ge B, Wei N, Mo Y, Qin G, Li H, Xu G. Hidden Telltale Signs in Hyperacute Ischemic Stroke Caused by Aortic Dissection: A Case Report and Post Hoc Analysis. Neurologist 2022; 27:350-353. [PMID: 34980835 PMCID: PMC9631774 DOI: 10.1097/nrl.0000000000000412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Rapid identification of hidden telltale signs in hyperacute ischemic stroke caused by aortic dissection (AD) is challenging, mainly owing to the narrow time window for bridging therapy. CASE REPORT A 63-year-old man was referred for sudden right-side weakness accompanied by a decreased level of consciousness for almost 1 hour and 37 minutes. He had a history of hypertension. His skin was clammy, and on physical examination, there was involuntary chest thumping in the left upper limb. Hyperacute cerebral infarction was considered after no bleeding was observed on emergency head computed tomography, and intravenous thrombolysis with alteplase was administered immediately after. The patient was then taken to the catheter room, ready for endovascular thrombectomy. Stanford type A AD was found by cerebral angiography before endovascular thrombectomy. The infusion of alteplase was stopped immediately during cerebral angiography, but the patient's blood pressure, heart rate, and blood oxygen were still declining progressively, and the degree of consciousness disturbance deepened. The patient died after the combined but failed rescue attempts of multiple departments. CONCLUSION Hyperacute ischemic stroke caused by AD often hides some telltale signs. Clinicians should master basic clinical skills to exclude AD by looking for these telltale signs hidden in hyperacute ischemic stroke to avoid the fatal consequences of intravenous thrombolysis and/or cerebral angiography within the narrow window of time.
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Chen SQ, Luo WL, Liu W, Wang LZ. Beware of the DeBakey type I aortic dissection hidden by ischemic stroke: Two case reports. World J Clin Cases 2022; 10:8673-8678. [PMID: 36157827 PMCID: PMC9453352 DOI: 10.12998/wjcc.v10.i24.8673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 06/13/2022] [Accepted: 07/22/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND DeBakey type I aortic dissection is one of the rare etiologies of ischemic stroke. It is critical to identify arterial dissection before intravenous thrombolysis; otherwise, fatal hemorrhage may occur.
CASE SUMMARY In this report, we described 2 painless DeBakey type I aortic dissection cases with initial symptoms similar to ischemic stroke. Sudden onset of conscious disturbance and limb weakness within minutes occurred in both cases. Hypotension was found in both cases. Thoracoabdominal computed tomography angiography was urgently performed due to unknown reason hypotension, and DeBakey type I aortic dissection was confirmed. Intravenous thrombolysis was avoided because of timely diagnosis; however, they both eventually died of ruptured aortic dissection.
CONCLUSION Aortic dissection should always be excluded in ischemic stroke patients with unexplained hypotension or shock symptoms before intravenous thrombolytic therapy.
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Affiliation(s)
- Su-Qin Chen
- Department of Neurology, Huizhou Central People's Hospital, Huizhou 516001, Guangdong Province, China
| | - Wei-Liang Luo
- Department of Neurology, Huizhou Central People's Hospital, Huizhou 516001, Guangdong Province, China
| | - Wu Liu
- Department of Neurology, Huizhou Central People's Hospital, Huizhou 516001, Guangdong Province, China
| | - Li-Zhi Wang
- Department of Neurology, Huizhou Central People's Hospital, Huizhou 516001, Guangdong Province, China
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Gong W, Zhou L, Shang L, Zhao H, Duan W, Zheng M, Ge S. Cerebral infarction and risk factors in acute type A aortic dissection with arch branch extension. Echocardiography 2022; 39:1113-1121. [PMID: 35861335 DOI: 10.1111/echo.15426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/21/2022] [Accepted: 07/03/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Stanford type A aortic dissection (AAD) may affect the supra-aortic arteries, which are associated with acute ischemic stroke (AIS) or transient ischemic attack (TIA). This study aimed to investigate cerebral perfusion, the infarction incidence and risk factors in AAD patients. METHODS A total of 156 consecutive AAD patients were enrolled and divided into two groups according to whether the aortic arch branches were involved: the affected group (n = 90) and the unaffected group (n = 66). Clinical, echocardiographic/carotid Doppler data and cerebral infarction morbidity were compared between the groups. Independent predictors of 30-day AAD mortality were identified through multivariable Cox regression, and perioperative risk factors were analyzed. RESULTS In total, 57.7% of AAD patients had aortic arch branch involvement. Abnormal Doppler waveforms were more common in the affected group (p < 0.05). Regarding intracranial perfusion, the blood flow volumes (BFVs) of the bilateral internal carotid arteries (ICAs) and right vertebral artery (RVA) in the affected group were significantly reduced (p < 0.05). The incidence of cerebral infarction in the affected group was significantly higher than that in the unaffected group (35.6% vs. 19.7%, p = 0.031). Multivariable analysis revealed that age >45 years old, right internal carotid artery (RICA) involvement and reduced left ventricular ejection fraction (LVEF) were significant predictors of perioperative death. CONCLUSIONS Aortic arch branch involvement is common in patients with AAD and is associated with reduced cerebral blood flow (especially on the right side) and a higher incidence of cerebral infarction. Age, extension of the RICA dissection and LVEF impairment are independent risk factors for AAD-related death.
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Affiliation(s)
- Wenqing Gong
- Department of Ultrasound, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Ling Zhou
- Department of Ultrasound, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Lei Shang
- Department of Health Statistics, School of Public Health, Fourth Military Medical University, Xi'an, China
| | - Hongliang Zhao
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Weixun Duan
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Minjuan Zheng
- Department of Ultrasound, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Shuping Ge
- Pediatric Cardiology, Drexel University College of Medicine, Philadelphia, USA
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Suda S, Abe A, Iguchi Y, Yagita Y, Kanzawa T, Okubo S, Ohara N, Mizunari T, Yamazaki M, Nakajima N, Kondo K, Fujimoto S, Inoue T, Iwanaga T, Terasawa Y, Shibazaki K, Kono Y, Nakajima M, Nakajima M, Mishina M, Adachi K, Imafuku I, Nomura K, Nagao T, Yaguchi H, Okamoto S, Osaki M, Kimura K. Characteristics of Ischemic Versus Hemorrhagic Stroke in Patients Receiving Oral Anticoagulants: Results of the PASTA Study. Intern Med 2022; 61:801-810. [PMID: 34483213 PMCID: PMC8987259 DOI: 10.2169/internalmedicine.8113-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Objective Limited data exist regarding the comparative detailed clinical characteristics of patients with ischemic stroke (IS)/transient ischemic attack (TIA) and intracerebral hemorrhage (ICH) receiving oral anticoagulants (OACs). Methods The prospective analysis of stroke patients taking oral anticoagulants (PASTA) registry, a multicenter registry of 1,043 stroke patients receiving OACs [vitamin K antagonists (VKAs) or non-vitamin K antagonist oral anticoagulant (NOACs)] across 25 medical institutions throughout Japan, was used. Univariate and multivariable analyses were used to analyze differences in clinical characteristics between IS/TIA and ICH patients with atrial fibrillation (AF) who were registered in the PASTA registry. Results There was no significant differences in cardiovascular risk factors, such as hypertension, diabetes mellitus, dyslipidemia, smoking, or alcohol consumption (all p>0.05), between IS/TIA and ICH among both NOAC and VKA users. Cerebral microbleeds (CMBs) [odds ratio (OR), 4.77; p<0.0001] were independently associated with ICH, and high brain natriuretic peptide/N-terminal pro B-type natriuretic peptide levels (OR, 1.89; p=0.0390) were independently associated with IS/TIA among NOAC users. A history of ICH (OR, 13.59; p=0.0279) and the high prothrombin time-international normalized ratio (PT-INR) (OR, 1.17; p<0.0001) were independently associated with ICH, and a history of IS/TIA (OR, 3.37; 95% CI, 1.34-8.49; p=0.0101) and high D-dimer levels (OR, 2.47; 95% CI, 1.05-5.82; p=0.0377) were independently associated with IS/TIA among VKA users. Conclusion The presence of CMBs, a history of stroke, natriuretic peptide and D-dimer levels, and PT-INR may be useful for risk stratification of either IS/TIA or ICH development in patients with AF receiving OACs.
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Affiliation(s)
- Satoshi Suda
- Department of Neurology, Nippon Medical School, Japan
| | - Arata Abe
- Department of Neurology and Stroke Medicine, Tokyo Metropolitan Tama Medical Center, Japan
| | - Yasuyuki Iguchi
- Department of Neurology, The Jikei University School of Medicine, Japan
| | - Yoshiki Yagita
- Department of Stroke Medicine, Kawasaki Medical School, Japan
| | - Takao Kanzawa
- Department of Stroke Medicine, Institute of Brain and Blood Vessels, Mihara Memorial Hospital, Japan
| | - Seiji Okubo
- Department of Cerebrovascular Medicine, NTT Medical Center Tokyo, Japan
| | - Nobuyuki Ohara
- Department of Neurology, Kobe City Medical Center General Hospital, Japan
| | - Takayuki Mizunari
- Department of Neurosurgery, Nippon Medical School Chiba Hokusoh Hospital, Japan
| | - Mineo Yamazaki
- Department of Neurology, Nippon Medical School Chiba Hokusoh Hospital, Japan
| | | | | | - Shigeru Fujimoto
- Division of Neurology, Department of Medicine, Jichi Medical University Hospital, Japan
| | - Takeshi Inoue
- Department of Stroke Medicine, Kawasaki Medical School General Medical Center, Japan
| | - Takeshi Iwanaga
- Department of Stroke Medicine, Japanese Red Cross Okayama Hospital, Japan
| | - Yuka Terasawa
- Department of Neurology, Brain Attack Center Ota Memorial Hospital, Japan
| | | | - Yu Kono
- Department of Neurology, Fuji City General Hospital, Japan
| | - Makoto Nakajima
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Japan
| | | | - Masahiro Mishina
- Department of Neuro-pathophysiological Imaging, Graduate School of Medicine, Nippon Medical School, Japan
| | - Koji Adachi
- Department of Neurological Surgery, Nippon Medical School Musashi-Kosugi Hospital, Japan
| | | | | | - Takehiko Nagao
- Department of Neurology, Nippon Medical School Tama Nagayama Hospital, Japan
| | - Hiroshi Yaguchi
- Department of Neurology, The Jikei University Kashiwa Hospital, Japan
| | | | - Masato Osaki
- Department of Cerebrovascular Medicine, Steel Memorial Yawata Hospital, Japan
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Japan
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Ke C, Wu H, Xi M, Shi W, Huang Q, Lu G. Clinical features and risk factors of postoperative in-hospital mortality following surgical repair of Stanford type A acute aortic dissection. BMC Cardiovasc Disord 2021; 21:392. [PMID: 34384373 PMCID: PMC8359018 DOI: 10.1186/s12872-021-02107-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 06/08/2021] [Indexed: 12/02/2022] Open
Abstract
Background To investigate the clinical features of patients with Stanford type A acute aortic dissection (AAD) and analyze the risk factors affecting postoperative in-hospital mortality rate. Methods
The demographic and clinical data were retrospectively collected and analyzed from 118 AAD patients admitted to the Affiliated Hospital of Hangzhou Normal University from June 2016 to April 2019. All patients underwent surgical treatment and were grouped into death and survival groups. The risk factors affecting postoperative in-hospital death were analyzed using multivariate logistic regression analysis. Results The male to female ratio in the patients was 3.8:1 and the mean age was 50.11 ± 9.91 years. The patient’s main comorbidities were hypertension (70.33%) and coronary heart disease (10.17%). The main symptoms included chest pain and back pain (72.89%). The highest incidence of complications was pericardial effusion (48.31%), followed by pleural effusion (22.88%). The mean systolic blood pressure, white blood cell count and D-dimer in the patients were over the ranges of normal people. The incidences of cardiac and renal insufficiency were 18.64% and 16.95% respectively, and the postoperative in-hospital mortality rate was 12.71%. Univariable analysis showed that age, renal insufficiency, cardiac insufficiency, D-dimer level, cardiopulmonary bypass time, operation time, blood transfusion volume and postoperative hemostasis were significant factors leading to the death (P < 0.05). Multivariate logistic regression analysis showed that age > 65, renal insufficiency, cardiopulmonary bypass time ≥ 250 min and postoperative hemostasis were independent risk factors for the death (P < 0.05). Conclusions AAD patients frequently have underlying diseases with pain as the main symptom. Age > 65 years, renal insufficiency, cardiopulmonary bypass time ≥ 250 min and postoperative hemostasis are significantly risk factors for postoperative mortality.
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Affiliation(s)
- Chen Ke
- Department of Cardiothoracic Surgery, The Affiliated Hospital of Hangzhou Normal University, 126 Wenzhou Road, Hangzhou, 310029, China
| | - Hao Wu
- Department of Cardiothoracic Surgery, The Affiliated Hospital of Hangzhou Normal University, 126 Wenzhou Road, Hangzhou, 310029, China.
| | - Min Xi
- General Ward of Internal Medicine, Dingqiao Hospital, Hangzhou, China
| | - Wei Shi
- Department of Cardiothoracic Surgery, The Affiliated Hospital of Hangzhou Normal University, 126 Wenzhou Road, Hangzhou, 310029, China
| | - Qihong Huang
- Department of Cardiothoracic Surgery, The Affiliated Hospital of Hangzhou Normal University, 126 Wenzhou Road, Hangzhou, 310029, China
| | - Guirong Lu
- Department of Cardiothoracic Surgery, The Affiliated Hospital of Hangzhou Normal University, 126 Wenzhou Road, Hangzhou, 310029, China
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Usui T, Suzuki K, Niinami H, Sakai S. Aortic dissection diagnosed on stroke computed tomography protocol: a case report. J Med Case Rep 2021; 15:299. [PMID: 34034814 PMCID: PMC8152142 DOI: 10.1186/s13256-021-02850-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 04/04/2021] [Indexed: 12/03/2022] Open
Abstract
Background Aortic dissection is one of the causes of stroke. Because cerebral infarction with aortic dissection is a contraindication to intravenous recombinant tissue plasminogen activator (rt-PA) therapy, exclusion of aortic dissection is necessary prior to its administration. However, imaging takes time to provide a diagnosis, possibly causing delays in surgical treatment. Case presentation A 65-year-old Japanese female patient was transported to the hospital for a suspected stroke, with back pain and left upper and lower extremity palsy which occurred while eating. Upon arrival at the hospital, the left lower limb paralysis had improved, but the left upper limb paralysis remained. Right back pain had also developed. A plain head computed tomography (CT) scan performed 110 minutes after onset showed no acute bleeding or infarction. Subsequent CT perfusion (CTP) showed acute perfusion disturbance in the right hemisphere without infarction, known as ischemic penumbra. The four-dimensional maximum-intensity projection image reconstructed from CTP showed a delayed enhancement at the right internal carotid and right middle cerebral arteries compared to the contralateral side, suggesting a proximal vascular lesion. Contrast helical CT from the neck to abdomen revealed an acute aortic dissection of Stanford type A with false lumen patency. The dissection extended to the proximal right common carotid artery. The patient underwent an emergency total arch replacement and open stent graft. After recovering well, the patient was ambulatory upon discharge from the hospital. The combination of plain head CT, CTP, and helical CT scan from the neck to abdomen enabled us to evaluate for stroke and aortic dissection within a short amount of time, allowing for early therapeutic intervention. Conclusions When acute stroke is suspected due to neurological deficits, plain head CT is the first choice for imaging diagnosis. The addition of cervical CT angiography can reliably exclude stroke due to aortic dissection. CTP can identify ischemic penumbra, which cannot be diagnosed by plain head CT or diffusion-weighted magnetic resonance imaging. These combined stroke CT protocols helped us avoid missing an aortic dissection.
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Affiliation(s)
- Takami Usui
- Department of Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
| | - Kazufumi Suzuki
- Department of Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Hiroshi Niinami
- Department of Cardiovascular Surgery, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Shuji Sakai
- Department of Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
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Sasamoto N, Akutsu K, Yamamoto T, Otsuka T, Sangen H, Hayashi H, Murata H, Miyachi H, Hosokawa Y, Tara S, Tokita Y, Miyata S, Morota T, Nitta T, Shimizu W. Characteristics of the Inter-arm Difference in Blood Pressure in Acute Aortic Dissection. J NIPPON MED SCH 2021; 88:467-474. [PMID: 33692296 DOI: 10.1272/jnms.jnms.2021_88-605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND An inter-arm difference in blood pressure (IADBP) is characteristic of acute aortic dissection (AAD), but which arm shows lower blood pressure (BP) and the mechanism of IADBP has not been fully elucidatedMethods: We identified consecutive patients with chest and/or back pain and suspected acute cardiovascular disease whose BP had been measured in both arms. We retrospectively compared the characteristics of such patients with AAD (n=93) to those without (non-AAD group, n=122). Additionally, we separately compared patients with type A AAD (TAAD group, n=58) or type B AAD (TBAD group, n=35) to non-AAD group. Characteristics included in these comparisons were patients' backgrounds and IADBP-related factors such as systolic BP (SBP) in the right arm (R) and left arm (L), R-L or L-R as the IADBP. Computed tomography (CT) findings of AD extending to the brachiocephalic artery (BCA) and/or left subclavian artery (LSCA) were examined in patients having IADBP. RESULTS In the TAAD group, the prevalence of R<130mmHg (38%-vs.-19%, p=0.009), L-R>15mmHg (19%-vs.-8%, p=0.047), L-R>20mmHg (14%-vs.-4%, p=0.029) was higher than in the non-AAD group. Multivariate analysis showed L-R>15mmHg with R<130mmHg was independently associated with TAAD (OR 25.97, 95% CI 2.45-275.67, p=0.007). However, IADBP-related factors were not associated with TBAD. AAD patients with L-R>20mmHg were all TAAD, and all aortic dissection extended to BCA just before the right common carotid artery on CT. CONCLUSIONS IADBP was characterized by R<L with low R in TAAD, but was not associated with TBAD.
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Affiliation(s)
- Nozomi Sasamoto
- Department of Cardiovascular Medicine, Nippon Medical School.,Division of Cardiovascular Intensive Care, Nippon Medical School Hospital
| | - Koichi Akutsu
- Department of Cardiovascular Medicine, Nippon Medical School.,Division of Cardiovascular Intensive Care, Nippon Medical School Hospital
| | - Takeshi Yamamoto
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital
| | - Toshiaki Otsuka
- Department of Hygiene and Public Health, Nippon Medical School.,Center for Clinical Research, Nippon Medical School Hospital
| | - Hideto Sangen
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital
| | - Hiroshi Hayashi
- Department of Cardiovascular Medicine, Nippon Medical School.,Division of Cardiovascular Intensive Care, Nippon Medical School Hospital
| | - Hiroshige Murata
- Department of Cardiovascular Medicine, Nippon Medical School.,Division of Cardiovascular Intensive Care, Nippon Medical School Hospital
| | - Hideki Miyachi
- Department of Cardiovascular Medicine, Nippon Medical School.,Division of Cardiovascular Intensive Care, Nippon Medical School Hospital
| | - Yusuke Hosokawa
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital
| | - Shuhei Tara
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital
| | - Yukichi Tokita
- Department of Cardiovascular Medicine, Nippon Medical School.,Division of Cardiovascular Intensive Care, Nippon Medical School Hospital
| | | | - Tetsuro Morota
- Department of Cardiovascular Surgery, Nippon Medical School
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School.,Division of Cardiovascular Intensive Care, Nippon Medical School Hospital
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10
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Cao L, Huang X, Zui FQ. Successful intravenous thrombolysis for acute ischemic stroke caused by aortic dissection with severe hypofibrinogenemia: a case report and literature review. Int J Neurosci 2021; 132:939-944. [PMID: 33393403 DOI: 10.1080/00207454.2020.1858823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Intravenous thrombolysis (IVT) for acute brain infarctions caused by aortic dissection (AD) may lead to fatal outcomes; thus, it should be ruled out, especially if hypofibrinogenemia occurs after IVT. Successful management of AD-related acute brain infarction with hypofibrinogenemia after IVT has not been reported previously. CASE REPORT An 84-year-old woman developed sudden left limb weakness and aphasia for almost 4 h. Alteplase was administered intravenously immediately after cerebral hemorrhage was ruled out by emergent head computed tomography (CT). An anomaly suspected to be AD was detected during subsequent routine chest CT, which was confirmed by CT angiography to be a thoracoabdominal aortic dissecting aneurysm (DeBakey type I). Severe hypofibrinogenemia was also noted. After effective blood pressure control, intramuscular injection of vitamin K, and rehydration therapy, her brain cell metabolism improved, hemiplegia improved slightly, and hypofibrinogenemia recovered gradually. The patient's cerebral hemorrhage did not progress, there was no chest pain or no aggravation of hemiplegia, and the fibrinogen level gradually returned to normal. The condition was stable during hospitalization. At 1.5 months after discharge, the patient showed minimal change in condition. CONCLUSION The symptoms of AD may be nonspecific and latent. IVT may be allowed to perform for some patients with AD related ischemical stroke, And IVT can improve the neural symptoms of AD-related ischemic stroke, but close monitoring is needed to avoid aneurysm rupture. Fibrinogen levels should also be monitored periodically after IVT for early detection of hypofibrinogenemia.
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Affiliation(s)
- Liming Cao
- Department of Neurology, The 3rd Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Xuming Huang
- Department of Gastroenterology, Shenzhen Shiyan People's Hospital, Shenzhen, China
| | - Fei-Qi Zui
- Department of Neurology, The 3rd Affiliated Hospital of Shenzhen University, Shenzhen, China
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11
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Zhao H, Ma W, Wen D, Duan W, Zheng M. Computed tomography angiography findings predict the risk factors for preoperative acute ischaemic stroke in patients with acute type A aortic dissection. Eur J Cardiothorac Surg 2020; 57:912-919. [PMID: 31898735 DOI: 10.1093/ejcts/ezz351] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 10/30/2019] [Accepted: 11/01/2019] [Indexed: 12/11/2022] Open
Abstract
Abstract
OBJECTIVES
Acute ischaemic stroke (AIS) is a highly dreaded complication of acute type A aortic dissection (ATAAD). Knowledge about independent predictors of preoperative AIS in patients with ATAAD remains unclear. The aim of this study was to identify the risk factors for preoperative AIS in patients with ATAAD by computed tomography angiography (CTA) findings.
METHODS
Between October 2014 and March 2017, 281 (217 male; mean age, 50 years) patients with ATAAD underwent aortic CTA and diffusion-weighted magnetic resonance imaging of the brain was used to confirm the results. The clinical data and CTA findings were evaluated retrospectively. Patients were divided into 2 groups depending on the presence or absence of preoperative AIS.
RESULTS
Preoperative AIS was detected in 103 (36.7%) of the patients with ATAAD. Univariable analysis of the clinical characteristics and CTA findings revealed that age, aortic valve insufficiency (moderate or severe), the ratio of the diameter of the true lumen of the ascending aorta to the diameter of the involved ascending aorta, intimal flap plaque, dissection of the common carotid artery (CCA), the lower density of the unilateral internal carotid artery, the CCA originating from the false lumen and dissection of the subclavian artery were implicated in patients with ATAAD with AIS. Multivariable analysis further showed that aortic valve insufficiency (moderate or severe) [odds ratio (OR) 2.033, 95% confidence interval (CI) 1.052–3.931; P = 0.035], 2 CTA findings including the ratio of the diameters (OR 0.074, 95% CI 0.011–0.516; P = 0.009) and dissection of the CCA (OR 2.422, 95% CI 1.389–4.224; P = 0.002) were independent risk predictors for preoperative AIS in patients with ATAAD. The lower density in the false lumen, the same enhancement in the true and false lumen with re-entry and the stenosis of the true lumen without re-entry significantly increased the risk of preoperative AIS in CCA dissection.
CONCLUSIONS
Aortic valve insufficiency (moderate or severe), the ratio of the diameters of the true and false lumens and CCA dissection are independent predictors of preoperative AIS in patients with ATAAD. The specific carotid and aortic CTA findings may help to predict the risk factors for preoperative AIS in patients with ATAAD.
Clinical registration number
20120216-4.
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Affiliation(s)
- Hongliang Zhao
- Department of Radiology, Xijing Hospital, Fourth Military University, Xi’an, China
| | - Wanling Ma
- Department of Radiology, Xijing Hospital, Fourth Military University, Xi’an, China
| | - Didi Wen
- Department of Radiology, Xijing Hospital, Fourth Military University, Xi’an, China
| | - Weixun Duan
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military University, Xi’an, China
| | - Minwen Zheng
- Department of Radiology, Xijing Hospital, Fourth Military University, Xi’an, China
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12
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Toyoda K, Koga M, Iguchi Y, Itabashi R, Inoue M, Okada Y, Ogasawara K, Tsujino A, Hasegawa Y, Hatano T, Yamagami H, Iwama T, Shiokawa Y, Terayama Y, Minematsu K. Guidelines for Intravenous Thrombolysis (Recombinant Tissue-type Plasminogen Activator), the Third Edition, March 2019: A Guideline from the Japan Stroke Society. Neurol Med Chir (Tokyo) 2019; 59:449-491. [PMID: 31801934 PMCID: PMC6923159 DOI: 10.2176/nmc.st.2019-0177] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yasuyuki Iguchi
- Department of Neurology, The Jikei University School of Medicine
| | | | - Manabu Inoue
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center
| | - Yasushi Okada
- Department of Cerebrovascular Medicine and Neurology, National Hospital Organization Kyushu Medical Center
| | | | - Akira Tsujino
- Department of Neurology and Strokology, Nagasaki University Hospital
| | | | - Taketo Hatano
- Department of Neurosurgery, Kokura Memorial Hospital
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital
| | - Toru Iwama
- Department of Neurosurgery, Gifu University School of Medicine
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13
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Ohara T, Farhoudi M, Bang OY, Koga M, Demchuk AM. The emerging value of serum D-dimer measurement in the work-up and management of ischemic stroke. Int J Stroke 2019; 15:122-131. [DOI: 10.1177/1747493019876538] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Elevated D-dimer levels are a marker of both thrombin formation and fibrinolysis. Currently D-dimer measurement is routinely used for ruling out venous thromboembolism and diagnosis/monitoring of disseminated intravascular coagulation. Recent emerging data suggest that D-dimer may become an important biomarker in ischemic stroke as well as in cardiovascular diseases. Aims To outline the clinical utility of D-dimer in work-up and management of ischemic stroke. Summary D-dimer measurement is most useful in stroke with active cancer as it can confirm etiologic diagnosis, predict recurrent stroke risk, and aid treatment decision in cancer-associated stroke. In cryptogenic stroke, high D-dimer levels can also provide clues for the cause of stroke as occult cancer and undetected cardiac embolic source as occult atrial fibrillation and may be helpful in treatment decision making of secondary stroke prevention. Serial D-dimer measurements should be further studied to monitor antithrombotic therapy effectiveness in both cardiogenic and cryptogenic etiologies. Conclusion Accumulating data suggests the utility of D-dimer test in the management of ischemic stroke, although the evidence is still limited. Future studies would clarify the role of D-dimer measurement in ischemic stroke.
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Affiliation(s)
- Tomoyuki Ohara
- Calgary Stroke Program, Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine University of Calgary, Calgary, Canada
- Department of Neurology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Mehdi Farhoudi
- Calgary Stroke Program, Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine University of Calgary, Calgary, Canada
- Neurosciences Research Center, Neurology Department, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Andrew M Demchuk
- Calgary Stroke Program, Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine University of Calgary, Calgary, Canada
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14
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Kim JH, Choi JB, Kim TY, Kim KH, Kuh JH. Simplified surgical approach to improve surgical outcomes in the center with a small volume of acute type A aortic dissection surgery. Technol Health Care 2019; 26:675-685. [PMID: 29966210 PMCID: PMC6218144 DOI: 10.3233/thc-171169] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND: Despite recent advances in surgical techniques and perioperative management, the surgical mortality of acute type A aortic dissection remains high. OBJECTIVE: In a hospital with few acute type A aortic dissection operations, we retrospectively investigated whether simplified surgical approach could obtain proper surgical outcomes. METHODS: Between October 2007 and December 2016, we performed emergency surgery in 99 patients who had acute type A aortic dissection, including replacement of the hemi-arch in 62 patients (63%) and total arch in 32 patients (32%) and aortic root surgery in 7 patients (7%). Surgical strategy has been simplified over time. RESULTS: We performed right axillary artery perfusion in 61 patients (62%) and antegrade cerebral perfusion in 78 patients (79%). During the last 3 years, in-hospital mortality was decreased to 4% (2/47). Preoperative unresolved shock was an independent predictor of hospital death. Although the patients with total arch replacement or aortic root surgery had a mean significantly long cardiopulmonary bypass or circulatory arrest time, in-hospital mortality or neurologic complications was not increased. CONCLUSIONS: Simplified surgical approach could provide a reasonable surgical outcome in acute type A aortic dissection surgery in a center with a small volume of acute aortic dissection surgery.
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Affiliation(s)
- Jong Hun Kim
- Department of Thoracic and Cardiovascular Surgery, Chonbuk National University Medical School, Jeonju, Chonbuk, Korea.,Research Institute of Clinical Medicine of Chonbuk National University, Jeonju, Chonbuk, Korea.,Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Chonbuk, Korea.,Department of Thoracic and Cardiovascular Surgery, Chonbuk National University Medical School, Jeonju, Chonbuk, Korea
| | - Jong Bum Choi
- Department of Thoracic and Cardiovascular Surgery, Chonbuk National University Medical School, Jeonju, Chonbuk, Korea.,Research Institute of Clinical Medicine of Chonbuk National University, Jeonju, Chonbuk, Korea.,Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Chonbuk, Korea.,Department of Thoracic and Cardiovascular Surgery, Chonbuk National University Medical School, Jeonju, Chonbuk, Korea
| | - Tae Youn Kim
- Department of Thoracic and Cardiovascular Surgery, Chonbuk National University Medical School, Jeonju, Chonbuk, Korea.,Department of Thoracic and Cardiovascular Surgery, Chonbuk National University Medical School, Jeonju, Chonbuk, Korea
| | - Kyung Hwa Kim
- Department of Thoracic and Cardiovascular Surgery, Chonbuk National University Medical School, Jeonju, Chonbuk, Korea.,Department of Thoracic and Cardiovascular Surgery, Chonbuk National University Medical School, Jeonju, Chonbuk, Korea
| | - Ja Hong Kuh
- Department of Thoracic and Cardiovascular Surgery, Chonbuk National University Medical School, Jeonju, Chonbuk, Korea.,Department of Thoracic and Cardiovascular Surgery, Chonbuk National University Medical School, Jeonju, Chonbuk, Korea
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15
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Acute ischemic stroke as a complication of Stanford type A acute aortic dissection: a review and proposed clinical recommendations for urgent diagnosis. Gen Thorac Cardiovasc Surg 2018; 66:439-445. [PMID: 29948797 DOI: 10.1007/s11748-018-0956-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 06/08/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Stanford type A acute aortic dissection requires emergency surgery. Because patients with ischemic stroke as a complication of Stanford type A acute aortic dissection do not often complain of chest or back pain, probably due to consciousness disturbance, amnesia, or aphasia, a fatal course following inappropriate intravenous rt-PA therapy and delay of appropriate surgical treatment sometimes occur. REVIEW AND PROPOSED RECOMMENDATIONS When treating any suspected stroke patients, emergency services and initial urgent care doctors should always suspect aortic dissection. Even in the absence of chest or back pain, the initial urgent care doctor needs to immediately perform chest contrast CT if suspecting aortic dissection from blood pressure laterality or upper mediastinal widening on chest X-ray. Whenever aortic dissection cannot be ruled out from initial clinical information, the initial urgent care doctor should evaluate the common carotid artery (CCA). Dissection extension to the CCA or flow abnormality of the CCA is often detected if aortic dissection is a cause of ischemic stroke or transient ischemic attack. Head CT or MRI including vascular imaging is preferable. D-dimer should be measured in hospitals where available. As soon as aortic dissection is identified, the initial urgent care doctor needs to consult with cardiovascular surgeons or cardiologists for appropriate treatment.
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16
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Matsubara S, Koga M, Ohara T, Iguchi Y, Minatoya K, Tahara Y, Fukuda T, Miyazaki Y, Kajimoto K, Sakamoto Y, Makita N, Tokuda N, Nagatsuka K, Ando Y, Toyoda K. Cerebrovascular imaging of cerebral ischemia in acute type A aortic dissection. J Neurol Sci 2018; 388:23-27. [PMID: 29627025 DOI: 10.1016/j.jns.2018.02.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 02/06/2018] [Accepted: 02/26/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Stanford type A aortic dissection (AAD) sometimes causes acute ischemic stroke (AIS) or transient ischemic attack (TIA). There is little understanding of cerebrovascular imaging of AIS or TIA in patients with AAD. METHODS Consecutive AIS/TIA patients with AAD who were admitted within 4.5 h of onset were reviewed. We compared findings of MRI/MRA between these and consecutive AIS/TIA patients without AAD within 4.5 h of onset. RESULTS Seventeen AAD and 249 non-AAD patients were identified. Compared to non-AAD patients, AAD patients had infarcts more frequently in the right anterior cerebral artery (ACA) territory (18% vs. 2%, P = 0.007) and the right middle cerebral artery (MCA) territory (71% vs. 29%, P < 0.001). There was no difference between the groups regarding whether it was perforator or cortical infarct, single or multiple infarcts, unilateral or bilateral infarcts, or ischemic change extension. On the MRA imaging, the AAD patients more frequently had poor visualization of the right internal carotid artery (ICA) (47% vs. 6%, P < 0.001). After adjustment for sex, age and confounding factors, the right ACA territory infarct [odds ratio (OR), 12.2; 95% confidence interval (CI), 1.4-119.4], the MCA territory infarct (OR, 4.9; 95% CI, 1.0-25.0) and poor visualization of the right ICA (OR, 18.1; 95% CI, 4.0-101.9) were independently associated with AAD. CONCLUSION In emergency AIS/TIA patients, right anterior circulation infarct and poor visualization of the right ICA on cerebrovascular imaging are potential imaging markers of AAD.
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Affiliation(s)
- Soichiro Matsubara
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan; Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Masatoshi Koga
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
| | - Tomoyuki Ohara
- Department of Neurology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yasuyuki Iguchi
- Department of Neurology, Jikei University School of Medicine, Tokyo, Japan
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yoshio Tahara
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Tetsuya Fukuda
- Department of Radiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yuichi Miyazaki
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Katsufumi Kajimoto
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yuki Sakamoto
- Department of Neurological Science, Nippon Medical School Hospital, Tokyo, Japan
| | - Naoki Makita
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Naoki Tokuda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kazuyuki Nagatsuka
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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17
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Tokuda N, Koga M, Ohara T, Minatoya K, Tahara Y, Higashi M, Miyazaki Y, Kajimoto K, Matsubara S, Makita N, Sakamoto Y, Iguchi Y, Mizuno T, Nagatsuka K, Toyoda K. Urgent Detection of Acute Type A Aortic Dissection in Hyperacute Ischemic Stroke or Transient Ischemic Attack. J Stroke Cerebrovasc Dis 2018; 27:2112-2117. [PMID: 29653804 DOI: 10.1016/j.jstrokecerebrovasdis.2018.03.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 02/06/2018] [Accepted: 03/12/2018] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND AND PURPOSE Urgent diagnosis of acute Stanford type A aortic dissection (AAD) in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA) is sometimes challenging. We assessed predictive values for markers of AAD in patients with AIS or TIA. METHODS Consecutive patients with AIS or TIA with AAD who presented to our emergency room within 4.5 hours of symptom onset between 2007 and 2014 were compared with patients without AAD seen between 2012 and 2014. RESULTS Data were obtained for 24 patients with AIS or TIA with AAD (15 women; mean age, 75 ± 12 years) and 812 patients without AAD (305 women; mean age, 73 ± 12 years). Compared with patients without AAD, patients with AAD displayed significantly higher systolic blood pressure (SBP) laterality (30 ± 20 mm Hg versus 12 ± 11 mm Hg), initial D-dimer concentration (median 38.1 µg/mL versus 1.3 µg/mL), and mediastinal width-to-chest width (M/C) ratio on x-ray (.35 ± .05 versus .29 ± .05), and more frequently showed common carotid artery (CCA) dissection on carotid ultrasonography (84% versus 1%) and pericardial effusion on echocardiography (43% versus 0%). Sensitivity and specificity to identify AAD were 80% and 75% for SBP laterality 17 mm Hg or greater; 100% and 86% for D-dimer concentration 4.1 µg/mL or greater; 75% and 76% for M/C ratio .32 or greater; 84% and 99% for CCA dissection; and 43% and 100% for pericardial effusion, respectively. CONCLUSIONS High D-dimer level may provide the most reliable screening test for AAD in patients with AIS or TIA. CCA dissection on ultrasonography appears to represent the most disease-specific finding and shows acceptable sensitivity.
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Affiliation(s)
- Naoki Tokuda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masatoshi Koga
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Japan.
| | - Tomoyuki Ohara
- Department of Neurology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoshio Tahara
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masahiro Higashi
- Department of Radiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yuichi Miyazaki
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Katsufumi Kajimoto
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Soichiro Matsubara
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Naoki Makita
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yuki Sakamoto
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Yasuyuki Iguchi
- Department of Neurology, Jikei University School of Medicine, Tokyo, Japan
| | - Toshiki Mizuno
- Department of Neurology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kazuyuki Nagatsuka
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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18
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Hasan TF, Rabinstein AA, Middlebrooks EH, Haranhalli N, Silliman SL, Meschia JF, Tawk RG. Diagnosis and Management of Acute Ischemic Stroke. Mayo Clin Proc 2018; 93:523-538. [PMID: 29622098 DOI: 10.1016/j.mayocp.2018.02.013] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 01/25/2018] [Accepted: 02/16/2018] [Indexed: 10/17/2022]
Abstract
Acute ischemic stroke (AIS) is among the leading causes of death and long-term disability. Intravenous tissue plasminogen activator has been the mainstay of acute therapy. Recently, several prospective randomized trials documented the value of endovascular revascularization in selected patients with large-vessel occlusion within the anterior circulation. This finding has led to a paradigm shift in the management of AIS, including wide adoption of noninvasive neuroimaging to assess vessel patency and tissue viability, with the supplemental and independent use of intravenous tissue plasminogen activator to improve clinical outcomes. In this article, we review the landmark studies on management of AIS and the current position on the diagnosis and management of AIS. The review also highlights the importance of early stabilization and prompt initiation of therapeutic interventions before, during, and after the diagnosis of AIS within and outside of the hospital.
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Affiliation(s)
- Tasneem F Hasan
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL
| | | | | | - Neil Haranhalli
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL
| | - Scott L Silliman
- Department of Neurology, University of Florida Health Science Center, Jacksonville, FL
| | | | - Rabih G Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL.
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19
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Strony R. Response to MS 16944: Diagnosing Acute Aortic Dissection with Aneurysmal Degeneration with Point of Care Ultrasound. Am J Emerg Med 2018; 36:505-506. [DOI: 10.1016/j.ajem.2017.12.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 12/22/2017] [Indexed: 11/25/2022] Open
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20
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Marroush TS, Boshara AR, Parvataneni KC, Takla R, Mesiha NA. Painless Aortic Dissection. Am J Med Sci 2016; 354:513-520. [PMID: 29173364 DOI: 10.1016/j.amjms.2016.11.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 10/18/2016] [Accepted: 11/01/2016] [Indexed: 01/02/2023]
Abstract
Painless aortic dissection (PAoD) has been previously linked to poor outcomes. We recently encountered a case of a patient with PAoD presenting with dyspnea; the clue to diagnosis was the presence of a loud aortic diastolic murmur. A systematic review of the literature revealed 86 other cases, 62% of which occurred in men with a mean age of 65 years. Left-sided neurologic deficits were the most common presentation, followed by dyspnea and bilateral lower extremity deficits. Pulse asymmetry was found in 53% of patients, as 29% had right-left asymmetry and 24% had upper-lower asymmetry. Cumulatively, 88% of the cases were type A dissection and 51% of the patients died. Erroneous application of fibrinolysis and anticoagulation occurred in multiple instances. PAoD is rare but potentially fatal; a high index of suspicion and a thorough cardiovascular examination are needed to establish the diagnosis before applying possible harmful interventions such as fibrinolysis, vasodilation or anticoagulation.
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Affiliation(s)
- Tariq S Marroush
- Department of Internal Medicine, St. John Hospital and Medical Center, Detroit, Michigan.
| | - Andrew R Boshara
- Department of Internal Medicine, St. John Hospital and Medical Center, Detroit, Michigan
| | - Kesav C Parvataneni
- Department of Cardiovascular Diseases, St. John Hospital and Medical Center, Detroit, Michigan
| | - Robert Takla
- Department of Emergency Medicine, St. John Hospital and Medical Center, Detroit, Michigan
| | - Nancy A Mesiha
- Department of Cardiovascular Diseases, St. John Hospital and Medical Center, Detroit, Michigan
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