Crucial role of carotid ultrasound for the rapid diagnosis of hyperacute aortic dissection complicated by cerebral infarction: A case report and literature review

Prospective study on ultrasound-guided stellate ganglion block improves cerebral blood flow in patients with stroke

OBJECTIVES

The effect of routine internal medicine and stroke rehabilitation treatment was not good. To confirm that ultrasound-guided stellate ganglion block (SGB) can improve cerebral blood flow in patients with stroke, Transcranial Doppler (TCD) and carotid ultrasound were used to monitor the cerebral blood flow parameters of ultrasound-guided SGB in patients with stroke.

METHODS

A prospective study of 40 patients with stroke from January 2021 to October 2022 randomly divided into two groups (group SGB: undergoing ultrasound-guided SGB and standard medical procedures, control group: undergoing standard medical procedures) with 20 cases in each was conducted in People's Hospital of Chongqing Liang Jiang New Area. TCD and carotid artery ultrasound were monitored before and after treatment. There were no significant differences in general data on age, gender, disease course, and stroke type between two groups (P>0.05).

RESULTS

After treatment, the bilateral ACA Vm of group SGB was significantly higher, the bilateral internal carotid artery RI and left VA RI were significantly lower than in control group (P<0.05). In group SGB, the Vm of bilateral MCA, bilateral PCA, right ACA, bilateral VA, and BA after treatment were significantly (P<0.05) increased compared to before treatment. PI of bilateral MCA, right ACA, and left VA after treatment were significantly (P<0.05) decreased compared to before treatment. RI of bilateral MCA, bilateral PCA, and bilateral VA after treatment were significantly (P<0.05) decreased compared to before treatment. Right internal carotid artery D after treatment was significantly (P<0.05) higher than before treatment. RI of bilateral internal carotid artery after treatment was significantly (P<0.05) lower than before treatment.

CONCLUSIONS

Ultrasound-guided stellate ganglion block could improve local cerebral blood flow and vascular compliance in patients with stroke, and reduce vascular resistance.

Hemiplegia in acute ischemic stroke: A comprehensive review of case studies and the role of intravenous thrombolysis and mechanical thrombectomy

Acute ischemic stroke is a significant health concern worldwide, often leading to long-term disability and decreased quality of life. Rapid and appropriate treatment is crucial for achieving optimal outcomes in these patients. Intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) are two commonly used interventions for acute ischemic stroke, but their effectiveness in improving neurological symptoms and functional outcomes in patients with hemiplegia remains uncertain. The aim of this work was to evaluate the impact of IVT and MT within a 4.5-h time frame on patients with acute ischemic stroke and hemiplegia. A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Relevant studies that assessed the impact of IVT and MT within 4.5-h on hemiplegia in patients with an acute ischemic stroke were included. Data were extracted and analyzed to determine the overall effects of these interventions. Most included case reports indicate positive outcomes in terms of neurological symptom improvement and functional recovery in patients with hemiplegia after receiving IVT and MT within the specified time frame. However, the heterogeneity among the patients and the limited use of IVT due to contraindications posed challenges in determining the most effective treatment option. The findings from the included studies demonstrate that both interventions led to a decrease in National Institutes of Health Stroke Scale scores, indicating an improvement in neurological symptoms. The results highlight the beneficial effects of early thrombolytic interventions and MT on the neurological status and functional outcomes of patients with an acute ischemic stroke.

Stenting in Brain Hemodynamic Injury of Carotid Origin Caused by Type A Aortic Dissection: Local Experience and Systematic Literature Review

In this study, we report our local experience of type A aortic dissections in patients with cerebral malperfusion treated with carotid stenting before or after aortic surgery, and present a systematic literature review on these patients treated either with carotid stenting (CS) before or after aortic surgery (AS) or with aortic and carotid surgery alone (ACS). We report on patients treated in our center with carotid stenting for brain hemodynamic injury of carotid origin caused by type A dissection since 2018, and a systematic review was conducted in PubMed for articles published from 1990 to 2021. Out of 5307 articles, 19 articles could be included with a total of 80 patients analyzed: 9 from our center, 29 patients from case reports, and 51 patients from two retrospective cohorts. In total, 8 patients were treated by stenting first, 72 by surgery first, and 7 by stenting after surgery. The mean age; initial NIHSS score; time from symptom onset to treatment; post-treatment clinical improvement; post-treatment clinical worsening; mortality rate; follow-up duration; and follow-up mRS were, respectively, for each group (local cohort, CS before AS, ACS, CS after AS): 71.2 ± 5.3 yo, 65.5 ± 11.0 yo; 65.3 ± 13.1 yo, 68.7 ± 5.8 yo; 4 ± 8.4, 11.3 ± 8.5, 14.3 ± 8.0, 0; 11.8 ± 14.3 h, 21 ± 39.3 h, 13.6 ± 17.8 h, 13 ± 17.2 h; 56%, 71%, 86%, 57%; 11%, 28%, 0%, 14%; 25%, 12.3%, 14%, 33%; 5.25 ± 2.9 months, 54 months, 6.8 ± 3.8 months, 14 ± 14.4 months; 1 ± 1; 0.25 ± 0.5, 1.3 ± 0.8, 0.68 ± 0.6. Preoperative carotid stenting for hemodynamic cerebral malperfusion by true lumen compression appears to be feasible, and could be effective and safe, although there is still a lack of evidence due to the absence of comparative statistical analysis. The literature, albeit growing, is still limited, and prospective comparative studies are needed.

Successful intravenous thrombolysis for acute ischemic stroke caused by aortic dissection with severe hypofibrinogenemia: a case report and literature review

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.

Clinical analysis of aortic dissection with sudden coma and paraplegia as the main symptoms

Objective

This study aimed to investigate the clinical characteristics of patients with aortic dissection presenting with neurological symptoms as the initial symptoms.

Methods

Clinical characteristics, radiological abnormalities, and prognosis were analyzed in two female patients with aortic dissection. The main clinical symptoms were sudden coma and paraplegia. A detailed clinical examination was performed and computed tomography scans were evaluated.

Results

The initial symptoms of the patients involved the nervous system. Chest and abdominal computed tomography scans were performed to confirm the diagnosis of aortic dissection. Both patients died.

Conclusion

Patients who present with nervous system symptoms as the first symptoms of aortic dissection, which lead to misdiagnosis and missing the diagnosis, are rare. Improvement in the understanding of this disease is required to ensure that patients receive a timely diagnosis in the early stages.

Carotid Artery Stenting for the Treatment of Fatal Acute Cerebral Infarction Associated with Aortic Dissection

Acute aortic dissection (AAD) complicated with acute cerebral infarction lacks a unified treatment plan. We report probably the most effective treatment of a type A AAD with acute cerebral infarction leading to coma. A 43-year-old man presented with acute hemiplegia and unconsciousness. He was diagnosed as acute cerebral infarction. After an ineffective emergency intravenous thrombolysis, a Digital Subtraction Angiography (DSA) examination revealed the severe cerebral artery occlusion, and the TICI 3 level was achieved by stent implantation in the left common carotid artery with significant neurological recovery. A type A AAD was found at the 1 month follow-up ultrasound examination and a further thoracic surgery was performed successfully. Carotid ultrasound is helpful for the diagnosis of AAD from acute cerebral infarction. Carotid artery stenting followed by thoracic surgery is effective in this kind of emergency situations. Further studies are needed to determine the exact indications.

The impact of development of atherosclerosis on delamination resistance of the thoracic aortic wall

The aim of this work is to determine the impact of development of atherosclerosis on dissection of the human thoracic aorta on the basis of an analysis of the mechanical properties of the interfaces between its layers. The research material consisted of 17 pathologically unchanged aortae and 74 blood vessels with atherosclerotic lesions, which were classified according to the histological classification by Stary. The subject of the analysis were the interfaces between the adventitia and the media-intima complex (A-MIC) and between the intima and the media-adventitia complex (I-MAC). The mechanical properties of the above interfaces were determined by the peeling test in the longitudinal and circumferential directions. The results indicate that development of atherosclerosis reduces vessel wall resistance to delamination. The greatest risk of dissection occurs at stage IV of the disease. In this case, energy values are lower by about 28% for the I-MAC interface and by 39% for the A-MIC interface compared with normal tissues. Lower values of mean force and energy were obtained for the I-MAC interface, indicating that this interface is more susceptible to delamination. The mechanical properties of the A-MIC interfaces are directional.