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Schaefer TC, Greive S, Bierwisch C, Mohseni-Mofidi S, Heiland S, Kramer M, Möhlenbruch MA, Bendszus M, Vollherbst DF. Iatrogenic air embolism: influence of air bubble size on cerebral infarctions in an experimental in vivo and numerical simulation model. J Neurointerv Surg 2024; 16:1036-1041. [PMID: 37673679 PMCID: PMC11420717 DOI: 10.1136/jnis-2023-020739] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 08/10/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Cerebral infarctions resulting from iatrogenic air embolism (AE), mainly caused by small air bubbles, are a well-known and often overlooked event in endovascular interventions. Despite their significance, the underlying pathophysiology remains largely unclear. METHODS In 24 rats, AEs were induced using a microcatheter, positioned in the carotid artery via femoral access. Rats were divided into two study groups, based on the size of the bubbles (85 and 120 µm) and two sub-groups, differing in air volume (0.39 and 0.64 µl). Ultra-high-field magnetic resonance imaging (MRI) was performed 1.5 hours after intervention. MRI findings including the number, single volume and total volume of the infarctions were assessed. A software-based numerical simulation was performed to qualitatively assess the microvascular pathomechanisms. RESULTS In the study groups 22 of 24 rats (92%) revealed cerebral infarctions. The number of infarctions per rat was higher for the smaller bubbles, for the lower (medians: 5 vs 3; p=0.049) and higher air volume sub-groups (medians: 6 vs 4; p=0.012). Correspondingly, total infarction volume was higher for the smaller bubbles (1.67 vs 0.5 mm³; p=0.042). Simulations confirmed the results of the experiments and suggested that fusion of microbubbles to larger bubbles is the underlying pathomechanism of vascular occlusions. CONCLUSION In iatrogenic AE, the size of the bubbles can have a major impact on the number and total volume of cerebral infarctions. These findings can help to better understand the pathophysiology of this frequent, often underestimated adverse event in endovascular interventions.
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Affiliation(s)
- Tabea C Schaefer
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Veterinary Clinical Sciences, Small Animal Clinic, Justus-Liebig-University Giessen, Giessen, Germany
| | - Svenja Greive
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | | | - Sabine Heiland
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Kramer
- Department of Veterinary Clinical Sciences, Small Animal Clinic, Justus-Liebig-University Giessen, Giessen, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Dominik F Vollherbst
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
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Loufopoulos G, Manaki V, Tasoudis P, Meintanopoulos AS, Kouvelos G, Ntaios G, Spanos K. New Ischemic Cerebral Lesions in Postprocedural Magnetic Resonance Imaging in Carotid Artery Stenting Versus Carotid Endarterectomy: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2024; 106:297-311. [PMID: 38825067 DOI: 10.1016/j.avsg.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/12/2024] [Accepted: 05/15/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND Recent randomized controlled trials (RCTs) have demonstrated similar outcomes in terms of ischemic stroke incidence after carotid endarterectomy (CEA) or carotid artery stenting (CAS) in asymptomatic carotid disease, while CEA seems to be the first option for symptomatic carotid disease. The aim of this meta-analysis is to assess the incidence of silent cerebral microembolization detected by magnetic resonance imaging (MRI) following these procedures. METHODS A systematic search was conducted using PubMed, Scopus, and Cochrane databases, including comparative studies involving symptomatic or asymptomatic patients undergoing either CEA or CAS and reporting on new cerebral ischemic lesions in postoperative MRI. The primary outcome was the newly detected cerebral ischemic lesions. Pooled effect estimates for all outcomes were calculated using the random-effects model. Prespecified random effects metaregression and subgroup analysis were conducted to examine the impact of moderator variables on the presence of new cerebral ischemic lesions. RESULTS 25 studies reporting on a total of 1827 CEA and 1500 CAS interventions fulfilled the eligibility criteria. The incidence of new cerebral ischemic lesions was significantly lower after CEA compared to CAS, regardless of the time of MRI assessment (first 24 hours; OR: 0.33, 95% CI: 0.17-0.64, P < 0.001), (the first 72 hours, OR: 0.25, 95% CI 0.18-0.36, P < 0.001), (generally within a week after the operation; OR: 0.24, 95% CI: 0.17-0.34, P < 0.001). Also, the rate of stroke (OR: 0.38, 95% CI: 0.23-0.63, P < 0.001) and the presence of contralateral new cerebral ischemic lesions (OR: 0.16, 95% CI 0.08-0.32, P < 0.001) were less frequent after CEA. Subgroup analysis based on the study design and the use of embolic protection device during CAS showed consistently lower rates of new lesions after CEA. CONCLUSIONS CEA demonstrates significant lower rates of new silent cerebral microembolization, as detected by MRI in postoperative period compared with CAS.
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Affiliation(s)
- Georgios Loufopoulos
- Cardiothoracic and Vascular Surgery Working Group, Society of Junior Doctors, Athens, Greece; Department of Surgery, Saint Imier Hospital, Saint Imier, Switzerland.
| | - Vasiliki Manaki
- Cardiothoracic and Vascular Surgery Working Group, Society of Junior Doctors, Athens, Greece; Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
| | - Panagiotis Tasoudis
- Cardiothoracic and Vascular Surgery Working Group, Society of Junior Doctors, Athens, Greece; Division of Cardiothoracic Surgery, Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - George Kouvelos
- Faculty of Medicine, Department of Vascular Surgery, University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - George Ntaios
- Faculty of Medicine, Department of Internal Medicine, University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Konstantinos Spanos
- Faculty of Medicine, Department of Vascular Surgery, University Hospital of Larissa, School of Health Sciences, University of Thessaly, Larissa, Greece
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Abdelkarim A, Straus SL, Moghaddam M, Nakhaei P, Clary B, Malas MB. Postoperative outcomes in patients with anemia undergoing carotid revascularization. J Vasc Surg 2024:S0741-5214(24)01777-4. [PMID: 39179005 DOI: 10.1016/j.jvs.2024.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 08/08/2024] [Accepted: 08/11/2024] [Indexed: 08/26/2024]
Abstract
BACKGROUND Preoperative anemia is associated with worse postoperative morbidity and mortality after major vascular procedures. Limited research has examined the optimal method of carotid revascularization in patients with anemia. Therefore, we aim to compare the postoperative outcomes after carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), and transcarotid artery revascularization (TCAR) among patients with anemia. STUDY DESIGN This is a retrospective review of patients with anemia undergoing CEA, TFCAS, and TCAR in the Vascular Quality Initiative database between 2016 and 2023. We defined anemia as a preoperative hemoglobin level of <13 g/dL in men and <12 g/dL in women. The primary outcomes were 30-day mortality and in-hospital major adverse cardiac events (MACEs). Logistic regression models were used for multivariate analyses. RESULTS Our study included 40,383 CEA (59.3%), 9159 TFCAS (13.5%), and 18,555 TCAR (27.3%) cases in patients with anemia. TCAR patients were older and had more medical comorbidities than CEA and TFCAS patients. TCAR was associated with decreased 30-day mortality (adjusted odds ratio [aOR], 0.45; 95% confidence interval [CI], 0.37-0.59; P < .001), in-hospital MACE (aOR, 0.58; 95% CI, 0.46-0.75; P < .001) compared with TFCAS. Additionally, TCAR was associated with a 20% decrease in the risk of 30-day mortality (aOR, 0.80; 95% CI, 0.65-0.98; P = .03) and a similar risk of in-hospital MACE (aOR, 0.86; 95% CI, 0.77-1.01; P = .07) compared with CEA. Furthermore, TFCAS was associated with an increased risk of 30-day mortality (aOR, 2; 95% CI, 1.5-2.68; P < .001) and in-hospital MACE (aOR, 1.7; 95% CI, 1.4-2; P < .001) compared with CEA. CONCLUSIONS In this multi-institutional national retrospective analysis of a prospectively collected database, TFCAS is associated with a high risk of 30-day mortality and in-hospital MACE compared with CEA and TCAR in patients with anemia. TCAR was associated with a lower risk of 30-day mortality compared with CEA. These findings suggest TCAR as the optimal minimally invasive procedure for carotid revascularization in patients with anemia.
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Affiliation(s)
- Ahmed Abdelkarim
- Division of Vascular & Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular and Endovascular Surgery, UC San Diego, San Diego, CA
| | - Sabrina L Straus
- Division of Vascular & Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular and Endovascular Surgery, UC San Diego, San Diego, CA
| | - Marjan Moghaddam
- Division of Vascular & Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular and Endovascular Surgery, UC San Diego, San Diego, CA
| | - Pooria Nakhaei
- Division of Vascular & Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular and Endovascular Surgery, UC San Diego, San Diego, CA
| | - Bryan Clary
- Division of Vascular & Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular and Endovascular Surgery, UC San Diego, San Diego, CA
| | - Mahmoud B Malas
- Division of Vascular & Endovascular Surgery, Department of Surgery, Center for Learning and Excellence in Vascular and Endovascular Surgery, UC San Diego, San Diego, CA.
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Ristow AVB, Massière B, Meirelles GV, Casella IB, Morales MM, Moreira RCR, Procópio RJ, Oliveira TF, de Araujo WJB, Joviliano EE, de Oliveira JCP. Brazilian Angiology and Vascular Surgery Society Guidelines for the treatment of extracranial cerebrovascular disease. J Vasc Bras 2024; 23:e20230094. [PMID: 39099701 PMCID: PMC11296686 DOI: 10.1590/1677-5449.202300942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 10/16/2023] [Indexed: 08/06/2024] Open
Abstract
Extracranial cerebrovascular disease has been the subject of intense research throughout the world, and is of paramount importance for vascular surgeons. This guideline, written by the Brazilian Society of Angiology and Vascular Surgery (SBACV), supersedes the 2015 guideline. Non-atherosclerotic carotid artery diseases were not included in this document. The purpose of this guideline is to bring together the most robust evidence in this area in order to help specialists in the treatment decision-making process. The AGREE II methodology and the European Society of Cardiology system were used for recommendations and levels of evidence. The recommendations were graded from I to III, and levels of evidence were classified as A, B, or C. This guideline is divided into 11 chapters dealing with the various aspects of extracranial cerebrovascular disease: diagnosis, treatments and complications, based on up-to-date knowledge and the recommendations proposed by SBACV.
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Affiliation(s)
- Arno von Buettner Ristow
- Pontifícia Universidade Católica do Rio de Janeiro – PUC-RIO, Disciplina de Cirurgia Vascular e Endovascular, Rio de Janeiro, RJ, Brasil.
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-RJ, Rio de Janeiro, RJ, Brasil.
| | - Bernardo Massière
- Pontifícia Universidade Católica do Rio de Janeiro – PUC-RIO, Disciplina de Cirurgia Vascular e Endovascular, Rio de Janeiro, RJ, Brasil.
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-RJ, Rio de Janeiro, RJ, Brasil.
| | - Guilherme Vieira Meirelles
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade Estadual de Campinas – UNICAMP, Hospital das Clínicas, Disciplina de Cirurgia do Trauma, Campinas, SP, Brasil.
| | - Ivan Benaduce Casella
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina, São Paulo, SP, Brasil.
| | - Marcia Maria Morales
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Associação Portuguesa de Beneficência de São José do Rio Preto, Serviço de Cirurgia Vascular, São José do Rio Preto, SP, Brasil.
| | - Ricardo Cesar Rocha Moreira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-PR, Curitiba, PR, Brasil.
- Pontifícia Universidade Católica do Paraná – PUC-PR, Hospital Cajurú, Serviço de Cirurgia Vascular, Curitiba, PR, Brasil.
| | - Ricardo Jayme Procópio
- Universidade Federal de Minas Gerais – UFMG, Hospital das Clínicas, Setor de Cirurgia Endovascular, Belo Horizonte, MG, Brasil.
- Universidade Federal de Minas Gerais – UFMG, Faculdade de Medicina, Belo Horizonte, MG, Brasil.
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-MG, Belo Horizonte, MG, Brasil.
| | - Tércio Ferreira Oliveira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SE, Aracajú, SE, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina de Ribeirão Preto – FMRP, Ribeirão Preto, SP, Brasil.
| | - Walter Jr. Boim de Araujo
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-PR, Curitiba, PR, Brasil.
- Universidade Federal do Paraná – UFPR, Hospital das Clínicas – HC, Curitiba, PR, Brasil.
| | - Edwaldo Edner Joviliano
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade de São Paulo – USP, Faculdade de Medicina de Ribeirão Preto – FMRP, Ribeirão Preto, SP, Brasil.
| | - Júlio Cesar Peclat de Oliveira
- Sociedade Brasileira de Angiologia e de Cirurgia Vascular – SBACV-SP, São Paulo, SP, Brasil.
- Universidade Federal do Estado do Rio de Janeiro – UNIRIO, Departamento de Cirurgia, Rio de Janeiro, RJ, Brasil.
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Osipova OS, Bugurov SV, Gostev AA, Saaya SB, Cheban AV, Ignatenko PV, Karpenko AA. Impact of shaggy aorta on intraoperative cerebral embolism during carotid artery stenting. INT ANGIOL 2024; 43:298-305. [PMID: 38801345 DOI: 10.23736/s0392-9590.24.05150-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
BACKGROUND Careful selection of patients for carotid stenting is necessary. We suggest that patients with a shaggy aorta syndrome may be at higher risk for perioperative embolic complications. METHODS The study is a retrospective subanalysis of the SIBERIA Trial. We included 72 patients undergoing transfemoral carotid artery stenting. Patients were monitored during the procedures using multifrequency transcranial Doppler with embolus detection and differentiation. Pre- and postprocedural (2 and 30 days) cerebral diffusion-weighted cerebral MRIs were performed. RESULTS Forty-six patients had shaggy aorta syndrome. Intraoperative embolisms were recorded in 82.6% and 46.1% of patients with and without shaggy aorta syndrome, respectively (P=0.001). New asymptomatic ischemic brain lesions in the postoperative period occurred in 78.3% and in 26.9% of patients with and without shaggy aorta syndrome, respectively (P<0.001). There were no cases of stroke within 2 days in both groups. 3 (6.5%) cases of stroke within 30 days after the procedure were observed only in patients with shaggy aorta syndrome. There were no cases of contralateral stroke. Shaggy aorta syndrome (OR 5.54 [1.83:16.7], P=0.001) and aortic arch ulceration (OR 6.67 [1.19: 37.3], P=0.02) were independently associated with cerebral embolism. Shaggy aorta syndrome (OR 9.77 [3.14-30.37], P<0.001) and aortic arch ulceration (OR 12.9 [2.3: 72.8], P=0.003) were independently associated with ipsilateral new asymptomatic ischemic brain lesions. CONCLUSIONS Shaggy aorta syndrome and aortic arch ulceration significantly increase the odds of intraoperative embolism and new asymptomatic ischemic brain lesions. Carotid endarterectomy or transcervical carotid stent should be selected in patients with shaggy aorta syndrome.
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Affiliation(s)
- Olesia S Osipova
- Center for Vascular and Hybrid Surgery, Meshalkin National Medical Research Center, Novosibirsk, Russia -
| | - Savr V Bugurov
- Center for Vascular and Hybrid Surgery, Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Alexander A Gostev
- Center for Vascular and Hybrid Surgery, Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Shoraan B Saaya
- Center for Vascular and Hybrid Surgery, Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Alexey V Cheban
- Center for Vascular and Hybrid Surgery, Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Pavel V Ignatenko
- Center for Vascular and Hybrid Surgery, Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Andrey A Karpenko
- Center for Vascular and Hybrid Surgery, Meshalkin National Medical Research Center, Novosibirsk, Russia
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Roopnarinesingh R, Leppert M, Mukherjee D. Evidence and Mechanisms for Embolic Stroke in Contralateral Hemispheres From Carotid Artery Sources. J Am Heart Assoc 2023; 12:e030792. [PMID: 38014680 PMCID: PMC10727331 DOI: 10.1161/jaha.123.030792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 08/23/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Disambiguation of embolus pathogenesis in embolic strokes is often a clinical challenge. One common source of embolic stroke is the carotid arteries, with emboli originating due to plaque buildup or perioperatively during revascularization procedures. Although it is commonly thought that thromboemboli from carotid sources travel to cerebral arteries ipsilaterally, there are existing reports of contralateral embolic events that complicate embolus source destination relationship for carotid sources. Here, we hypothesize that emboli from carotid sources can travel to contralateral hemispheres and that embolus interactions with collateral hemodynamics in the circle of Willis influence this process. METHODS AND RESULTS We use a patient-specific computational embolus-hemodynamics interaction model developed in prior works to conduct an in silico experiment spanning 4 patient vascular models, 6 circle of Willis anastomosis variants, and 3 different thromboembolus sizes released from left and right carotid artery sites. This led to a total of 144 different experiments, estimating trajectories and distribution of approximately 1.728 million embolus samples. Across all cases considered, emboli from left and right carotid sources showed nonzero contralateral transport (P value <-0.05). Contralateral movement revealed a size dependence, with smaller emboli traveling more contralaterally. Detailed analysis of embolus dynamics revealed that collateral flow routes in the circle of Willis played a role in routing emboli, and transhemispheric movement occurred through the anterior and posterior communicating arteries in the circle of Willis. CONCLUSIONS We generated quantitative data demonstrating the complex dynamics of finite size thromboembolus particles as they interact with pulsatile arterial hemodynamics and traverse the vascular network of the circle of Willis. This leads to a nonintuitive source-destination relationship for emboli originating from carotid artery sites, and emboli from carotid sources can potentially travel to cerebral arteries on contralateral hemispheres.
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Affiliation(s)
| | - Michelle Leppert
- Department of NeurologyUniversity of Colorado Anschutz Medical CampusAuroraCO
| | - Debanjan Mukherjee
- Paul M Rady Department of Mechanical EngineeringUniversity of Colorado BoulderBolderCO
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Hsu AC, Williams B, Ding L, Weaver FA, Han SM, Magee GA. Risk Factors for Cerebral Hyperperfusion Syndrome following Carotid Revascularization. Ann Vasc Surg 2023; 97:89-96. [PMID: 37356658 DOI: 10.1016/j.avsg.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/31/2023] [Accepted: 06/04/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Cerebral hyperperfusion syndrome (CHS) is a rare but known complication of carotid revascularization that can result in severe postoperative disability and death. CHS is a well-described sequela of carotid endarterectomy (CEA) and, more recently, of transfemoral carotid artery stenting (TFCAS), but its incidence after transcarotid artery revascularization (TCAR) has not been delineated. The aims of this study were to determine the impact of procedure type (CEA versus TCAR versus TFCAS) on the development of CHS as well as to identify perioperative risk factors associated with CHS. METHODS The Society for Vascular Surgery Vascular Quality Initiative was queried for patients aged ≥18 years who underwent CEA, TCAR, or TFCAS from 2015-2021. Emergent procedures were excluded. The primary outcome was postoperative development of CHS, defined as the presence of postoperative seizures, intracerebral hemorrhage due to hyperperfusion, or both. Bivariate and multivariable logistic regression analyses were performed to identify factors associated with CHS. RESULTS 156,003 procedures were included (72.7% CEA, 12.4% TCAR, and 14.9% TFCAS). The incidence of CHS after CEA, TCAR, and TFCAS were 0.15%, 0.18%, and 0.53%, respectively. There was no significant difference in risk of CHS after TFCAS compared to CEA (odds ratio [OR]: 1.21; 95% confidence interval [CI] 0.76-1.92; P = 0.416), nor was there a difference between TCAR and CEA (OR: 0.91; 95% CI 0.57-1.45; P = 0.691). Perioperative risk factors associated with an increased risk of CHS included previous history of transient ischemic attack or stroke (OR: 2.50; 95% CI 1.69-3.68; P < 0.0001), necessity for urgent intervention within 48 hr (OR: 2.03; 95% CI 1.43-2.89; P < 0.0001), treatment of a total occlusion (OR: 3.80; 95% CI 1.16-12.47; P = 0.028), and need for postoperative intravenous blood pressure medication (OR: 5.45; 95% CI 3.97-7.48; P < 0.0001). Age, preoperative hypertension, degree of ipsilateral stenosis less than or equal to 99%, and history of prior carotid procedures were not statistically associated with an increased risk of CHS. Discharging patients on an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker was associated with a decreased risk of developing CHS (OR: 0.47; 95% CI 0.34-0.65; P < 0.0001). CONCLUSIONS Compared with CEA, TCAR and TFCAS were not statistically associated with an increased risk of postoperative CHS. Patients with a previous history of transient ischemic attack or stroke, who require urgent intervention or postoperative intravenous blood pressure medication, or who are treated for a total occlusion are at a higher risk of developing CHS. Using an angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker on discharge appears to be protective against CHS and should be considered for the highest risk patients.
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Affiliation(s)
- Ashley C Hsu
- Division of Vascular Surgery and Endovascular Therapy, Keck Medicine of USC, Los Angeles, CA
| | - Brian Williams
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Li Ding
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA
| | - Fred A Weaver
- Division of Vascular Surgery and Endovascular Therapy, Keck Medicine of USC, Los Angeles, CA
| | - Sukgu M Han
- Division of Vascular Surgery and Endovascular Therapy, Keck Medicine of USC, Los Angeles, CA
| | - Gregory A Magee
- Division of Vascular Surgery and Endovascular Therapy, Keck Medicine of USC, Los Angeles, CA.
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8
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Pelz DM, Lownie SP, Iftikhar UF, Munoz C, Lopez-Ojeda P, Azarpazhooh R. Safety Evaluation of Primary Carotid Stenting: Transcranial Doppler and MRI. Can J Neurol Sci 2023; 50:651-655. [PMID: 36245094 DOI: 10.1017/cjn.2022.304] [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: 11/08/2022]
Abstract
BACKGROUND AND PURPOSE Cerebral emboli are generated by every step of standard carotid angioplasty and stenting. Primary carotid stenting (PCS) is a technique in which the use of balloon angioplasty (BA) is minimized to decrease the embolic load. The primary aim of this study is to establish the number of emboli generated by each step of primary stenting and determine the relationship to new diffusion (DWI) lesions on subsequent magnetic resonance imaging (MRI). METHODS Eighty-five patients with severe, symptomatic carotid stenosis were prospectively recruited and underwent carotid stenting. Intraoperative transcranial Doppler was performed in 77 patients. The number and size of microemboli for each of seven procedural steps were recorded. Correlation was made with the number and location of new DWI lesions. RESULTS PCS was performed in 73 patients. BA was required in 12 patients. The mean number of microemboli was 114, and most microemboli were generated by stent deployment, followed by BA. Balloon techniques generated significantly more emboli than primary stenting (p = 0.017). There was a significant relationship between total microemboli and new DWI lesions (p = 0.009), and between new DWI lesions in multiple territories and the severity of pretreatment stenosis (p = 0.002). CONCLUSIONS During PCS, more emboli are generated by stent deployment than during any other stage of the procedure. When BA is necessary, more malignant emboli are generated but total emboli are unchanged and there is no difference in new diffusion lesions on MRI. PCS is safe and is not inferior to historical controls for the generation of new DWI lesions.
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Affiliation(s)
- David M Pelz
- Departments of Medical Imaging and Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Stephen P Lownie
- Departments of Medical Imaging and Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Division of Neurosurgery, Dalhousie University, Halifax, NS, Canada
| | - Urooj F Iftikhar
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Claudio Munoz
- Robarts Research Institute, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | | | - Reza Azarpazhooh
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Surgery, Western University, London, ON, Canada
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9
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Roopnarinesingh R, Leppert M, Mukherjee D. Evidence And Mechanisms For Embolic Stroke In Contralateral Hemispheres From Carotid Artery Sources. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.04.20.23288892. [PMID: 37162897 PMCID: PMC10168406 DOI: 10.1101/2023.04.20.23288892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Disambiguation of embolus etiology in embolic strokes is often a clinical challenge. One common source of embolic stroke is the carotid arteries, with emboli originating due to plaque build up, or perioperatively during revascularization procedures. While it is commonly thought that thromboemboli from carotid sources travel to cerebral arteries ipsilaterally, there are existing reports of contralateral embolic events which complicate embolus source destination relationship for carotid sources. Here, we hypothesize that emboli from carotid sources can travel to contralateral hemispheres, and that embolus interactions with collateral hemodynamics in the Circle of Willis influences this process. We use a patient-specific computational embolus-hemodynamics interaction model developed in prior works to conduct an in silico experiment spanning 4 patient vascular models, 6 Circle of Willis anastomosis variants, and 3 different thromboembolus sizes released from left and right carotid artery sites. This led to a total of 144 different experiments, estimating trajectories and distribution of approximately 1.728 million embolus samples. Across all cases considered, emboli from left and right carotid sources showed non-zero contralateral transport (p value < 0.05). Contralateral movement revealed a size-dependence, with smaller emboli traveling more contralaterally. Detailed analysis of embolus dynamics revealed that collateral flow routes in Circle of Willis played a role in routing emboli, and transhemispheric movement occurred through the anterior and posterior communicating arteries in the Circle of Willis. We generated quantitative data demonstrating the complex dynamics of finite size thromboembolus particles as they interact with pulsatile arterial hemodynamics, and traverse the vascular network of the Circle of Willis. This leads to a non-intuitive source-destination relationship for emboli originating from carotid artery sites, and emboli from carotid sources can potentially travel to cerebral arteries on contralateral hemispheres.
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D'Andrea A, Fabiani D, Cante L, Caputo A, Sabatella F, Riegler L, Alfano G, Russo V. Transcranial Doppler ultrasound: Clinical applications from neurological to cardiological setting. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:1212-1223. [PMID: 36218211 DOI: 10.1002/jcu.23344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 06/16/2023]
Abstract
Transcranial Doppler (TCD) ultrasonography is a rapid, noninvasive, real-time, and low-cost imaging technique. It is performed with a low-frequency (2 MHz) probe in order to evaluate the cerebral blood flow (CBF) and its pathological alterations, through specific acoustic windows. In the recent years, TCD use has been expanded across many clinical settings. Actually, the most widespread indication for TCD exam is represented by the diagnosis of paradoxical embolism, due to patent foramen ovale, in young patients with cryptogenic stroke. In addition, TCD has also found useful applications in neurological care setting, including the following: cerebral vasospasm following acute subarachnoid hemorrhage, brain trauma, cerebrovascular atherosclerosis, and evaluation of CBF and cerebral autoregulation after an ischemic stroke event. The present review aimed to describe the most recent evidences of TCD utilization from neurological to cardiological setting.
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Affiliation(s)
- Antonello D'Andrea
- Cardiology Unit, Umberto I Hospital, University of Campania "Luigi Vanvitelli", Nocera Inferiore, Italy
| | - Dario Fabiani
- Cardiology Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Luigi Cante
- Cardiology Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Adriano Caputo
- Cardiology Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Francesco Sabatella
- Cardiology Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Lucia Riegler
- Cardiology Unit, Umberto I Hospital, University of Campania "Luigi Vanvitelli", Nocera Inferiore, Italy
| | - Gabriele Alfano
- Cardiology Unit, Umberto I Hospital, University of Campania "Luigi Vanvitelli", Nocera Inferiore, Italy
| | - Vincenzo Russo
- Cardiology Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, Naples, Italy
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Matsuo K, Fujita A, Hosoda K, Tanaka J, Imahori T, Ishii T, Kohta M, Tanaka K, Uozumi Y, Kimura H, Sasayama T, Kohmura E. Potential of machine learning to predict early ischemic events after carotid endarterectomy or stenting: a comparison with surgeon predictions. Neurosurg Rev 2021; 45:607-616. [PMID: 34080079 DOI: 10.1007/s10143-021-01573-7] [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: 02/22/2021] [Revised: 04/26/2021] [Accepted: 05/26/2021] [Indexed: 11/26/2022]
Abstract
Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are recommended for high stroke-risk patients with carotid artery stenosis to reduce ischemic events. However, we often face difficulty in determining the best treatment strategy. We aimed to develop an accurate post-CEA/CAS outcome prediction model using machine learning that will serve as a basis for a new decision support tool for patient-specific treatment planning. Retrospectively collected data from 165 consecutive patients with carotid stenosis underwent CEA or CAS and were divided into training and test samples. The following five machine learning algorithms were tuned, and their predictive performance was evaluated by comparison with surgeon predictions: an artificial neural network, logistic regression, support vector machine, random forest, and extreme gradient boosting (XGBoost). Seventeen clinical factors were introduced into the models. Outcome was defined as any ischemic stroke within 30 days after treatment including asymptomatic diffusion-weighted imaging abnormalities. The XGBoost model performed the best in the evaluation; its sensitivity, specificity, positive predictive value, and accuracy were 31.9%, 94.6%, 47.2%, and 86.2%, respectively. These statistical measures were comparable to those of surgeons. Internal carotid artery peak systolic velocity, low-density lipoprotein cholesterol, and procedure (CEA or CAS) were the most contributing factors according to the XGBoost algorithm. We were able to develop a post-procedural outcome prediction model comparable to surgeons in performance. The accurate outcome prediction model will make it possible to make a more appropriate patient-specific selection of CEA or CAS for the treatment of carotid artery stenosis.
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Affiliation(s)
- Kazuya Matsuo
- Department of Neurosurgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.
| | - Atsushi Fujita
- Department of Neurosurgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Kohkichi Hosoda
- Department of Neurosurgery, Kobe City Nishi-Kobe Medical Center, Kobe, Hyogo, Japan
| | - Jun Tanaka
- Department of Neurosurgery, Konan Hospital, Kobe, Hyogo, Japan
| | - Taichiro Imahori
- Department of Neurosurgery, Hyogo Brain and Heart Center at Himeji, Himeji, Hyogo, Japan
| | - Taiji Ishii
- Department of Neurosurgery, Toyooka Hospital, Toyooka, Hyogo, Japan
| | - Masaaki Kohta
- Department of Neurosurgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Kazuhiro Tanaka
- Department of Neurosurgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Yoichi Uozumi
- Department of Neurosurgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Hidehito Kimura
- Department of Neurosurgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Takashi Sasayama
- Department of Neurosurgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Eiji Kohmura
- Department of Neurosurgery, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
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Cornwell WK, Ambardekar AV, Tran T, Pal JD, Cava L, Lawley J, Tarumi T, Cornwell CL, Aaronson K. Stroke Incidence and Impact of Continuous-Flow Left Ventricular Assist Devices on Cerebrovascular Physiology. Stroke 2019; 50:542-548. [PMID: 30602359 DOI: 10.1161/strokeaha.118.022967] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- William K Cornwell
- From the Division of Cardiology, Department of Internal Medicine (W.K.C., A.V.A.), University of Colorado, Anschutz Medical Campus, Aurora
| | - Amrut V Ambardekar
- From the Division of Cardiology, Department of Internal Medicine (W.K.C., A.V.A.), University of Colorado, Anschutz Medical Campus, Aurora
| | - Tomio Tran
- Department of Internal Medicine (T. Tran), University of Colorado, Anschutz Medical Campus, Aurora
| | - Jay D Pal
- Division of Cardiothoracic Surgery, Department of Surgery (J.D.P.), University of Colorado, Anschutz Medical Campus, Aurora
| | - Luis Cava
- Department of Neurosurgery (L.C.), University of Colorado, Anschutz Medical Campus, Aurora
| | - Justin Lawley
- Division of Physiology, Department of Sports Science, University of Innsbruck, Austria (J.L.)
| | - Takashi Tarumi
- Human Informatics Research Institute, National Institute of Advanced Industrial Science and Technology, Tsukuba, Ibaraki, Japan (T. Tarumi)
| | | | - Keith Aaronson
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor (K.A.)
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Kolvenbach RR. Current role of transcervical carotid artery stenting with flow reversal. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2019. [DOI: 10.23736/s1824-4777.19.01423-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Traenka C, Engelter ST, Brown MM, Dobson J, Frost C, Bonati LH. Silent brain infarcts on diffusion-weighted imaging after carotid revascularisation: A surrogate outcome measure for procedural stroke? A systematic review and meta-analysis. Eur Stroke J 2019; 4:127-143. [PMID: 31259261 DOI: 10.1177/2396987318824491] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 12/20/2018] [Indexed: 12/13/2022] Open
Abstract
Aim To investigate whether lesions on diffusion-weighted imaging (DWI+) after carotid artery stenting (CAS) or endarterectomy (CEA) might provide a surrogate outcome measure for procedural stroke. Materials and Methods Systematic MedLine® database search with selection of all studies published up to the end of 2016 in which DWI scans were obtained before and within seven days after CAS or CEA. The correlation between the underlying log odds of stroke and of DWI+ across all treatment groups (i.e. CAS or CEA groups) from included studies was estimated using a bivariate random effects logistic regression model. Relative risks of DWI+ and stroke in studies comparing CAS vs. CEA were estimated using fixed-effect Mantel-Haenszel models. Results We included data of 4871 CAS and 2099 CEA procedures (85 studies). Across all treatment groups (CAS and CEA), the log odds for DWI+ was significantly associated with the log odds for clinically manifest stroke (correlation coefficient 0.61 (95% CI 0.27 to 0.87), p = 0.0012). Across all carotid artery stenting groups, the correlation coefficient was 0.19 (p = 0.074). There were too few CEA groups to reliably estimate a correlation coefficient in this subset alone. In 19 studies comparing CAS vs. CEA, the relative risks (95% confidence intervals) of DWI+ and stroke were 3.83 (3.17-4.63, p < 0.00001) and 2.38 (1.44-3.94, p = 0.0007), respectively. Discussion This systematic meta-analysis demonstrates a correlation between the occurrence of silent brain infarcts on diffusion-weighted imaging and the risk of clinically manifest stroke in carotid revascularisation procedures. Conclusion Our findings strengthen the evidence base for the use of DWI as a surrogate outcome measure for procedural stroke in carotid revascularisation procedures. Further randomised studies comparing treatment effects on DWI lesions and clinical stroke are needed to fully establish surrogacy.
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Affiliation(s)
- Christopher Traenka
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging and Rehabilitation, Felix Platter Hospital, Basel, Switzerland
| | - Stefan T Engelter
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging and Rehabilitation, Felix Platter Hospital, Basel, Switzerland
| | - Martin M Brown
- Stroke Research Group, Department of Brain Repair & Rehabilitation, UCL Institute of Neurology, London, UK
| | - Joanna Dobson
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Chris Frost
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Leo H Bonati
- Stroke Center and Department of Neurology, University Hospital Basel and University of Basel, Basel, Switzerland.,Stroke Research Group, Department of Brain Repair & Rehabilitation, UCL Institute of Neurology, London, UK
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Cerebral embolic protection in thoracic endovascular aortic repair. J Vasc Surg 2018; 68:1656-1666. [DOI: 10.1016/j.jvs.2017.11.098] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 11/27/2017] [Indexed: 01/14/2023]
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Rosen AC, Soman S, Bhat J, Laird AR, Stephens J, Eickhoff SB, Fox PM, Long B, Dinishak D, Ortega M, Lane B, Wintermark M, Hitchner E, Zhou W. Convergence Analysis of Micro-Lesions (CAML): An approach to mapping of diffuse lesions from carotid revascularization. NEUROIMAGE-CLINICAL 2018; 18:553-559. [PMID: 29868451 PMCID: PMC5984594 DOI: 10.1016/j.nicl.2018.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 12/19/2017] [Accepted: 01/18/2018] [Indexed: 11/25/2022]
Abstract
Carotid revascularization (endarterectomy, stenting) prevents stroke; however, procedure-related embolization is common and results in small brain lesions easily identified by diffusion weighted magnetic resonance imaging (DWI). A crucial barrier to understanding the clinical significance of these lesions has been the lack of a statistical approach to identify vulnerable brain areas. The problem is that the lesions are small, numerous, and non-overlapping. Here we address this problem with a new method, the Convergence Analysis of Micro-Lesions (CAML) technique, an extension of the Anatomic Likelihood Analysis (ALE). The method combines manual lesion tracing, constraints based on known lesion patterns, and convergence analysis to represent regions vulnerable to lesions as probabilistic brain atlases. Two studies were conducted over the course of 12 years in an active, vascular surgery clinic. An analysis in an initial group of 126 patients at 1.5 T MRI was cross-validated in a second group of 80 patients at 3T MRI. In CAML, lesions were manually defined and center points identified. Brains were aligned according to side of surgery since this factor powerfully determines lesion distribution. A convergence based analysis, was performed on each of these groups. Results indicated the most consistent region of vulnerability was in motor and premotor cortex regions. Smaller regions common to both groups included the dorsolateral prefrontal cortex and medial parietal regions. Vulnerability of motor cortex is consistent with previous work showing changes in hand dexterity associated with these procedures. The consistency of CAML also demonstrates the feasibility of this new approach to characterize small, diffuse, non-overlapping lesions in patients with multifocal pathologies. Convergence Analysis of Micro-Lesions technique finds patterns in diffuse lesions. Lesions from carotid revascularization affect consistent brain targets. Motor cortex is the most vulnerable brain region to these lesions.
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Affiliation(s)
- Allyson C Rosen
- Palo Alto Veterans Affairs Health Care System, Palo Alto, CA 94304, United States; Department of Psychiatry, Stanford University, Stanford, CA 94305, United States.
| | - Salil Soman
- Palo Alto Veterans Affairs Health Care System, Palo Alto, CA 94304, United States; Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Radiology, Boston, MA 00215, United States
| | - Jyoti Bhat
- Palo Alto Veterans Affairs Health Care System, Palo Alto, CA 94304, United States; Palo Alto Veterans Institute for Research, Palo Alto, CA 94304, United States
| | - Angela R Laird
- Department of Physics, School of Integrated Science and Humanity, Florida International University, Miami, FL 33199, United States
| | - Jeffrey Stephens
- Palo Alto Veterans Affairs Health Care System, Palo Alto, CA 94304, United States
| | - Simon B Eickhoff
- Institute of Systems Neuroscience, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany; Institute of Neuroscience and Medicine, Brain & Behaviour (INM-7), Research Centre Jülich, Jülich, Germany
| | - P Mickle Fox
- Research Imaging Institute, The University of Texas Health Science Center at San Antonio, TX 78229, United States
| | - Becky Long
- Department of Surgery, Stanford University, Stanford, CA 94305, United States; Department of Surgery, Texas Tech University Health Science Center El Paso, TX 79905, United States
| | - David Dinishak
- Palo Alto University, Redwood City, CA 94063, United States
| | - Mario Ortega
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, United States
| | - Barton Lane
- Palo Alto Veterans Affairs Health Care System, Palo Alto, CA 94304, United States; Department of Radiology, Stanford University, Stanford, CA 94305, United States
| | - Max Wintermark
- Palo Alto Veterans Affairs Health Care System, Palo Alto, CA 94304, United States; Department of Radiology, Stanford University, Stanford, CA 94305, United States
| | - Elizabeth Hitchner
- Palo Alto Veterans Affairs Health Care System, Palo Alto, CA 94304, United States; Department of Vascular Surgery, Stanford University, Stanford, CA 94305, United States
| | - Wei Zhou
- Palo Alto Veterans Affairs Health Care System, Palo Alto, CA 94304, United States; Department of Vascular Surgery, Stanford University, Stanford, CA 94305, United States; Department of Surgery, Tucson, AZ 85724-5066, United States
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Cerebral Gaseous Microemboli are Detectable During Continuous Venovenous Hemodialysis in Critically Ill Patients: An Observational Pilot Study. J Neurosurg Anesthesiol 2018; 29:236-242. [PMID: 26998647 DOI: 10.1097/ana.0000000000000296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Continuous venovenous hemodialysis (CVVHD) may generate microemboli that cross the pulmonary circulation and reach the brain. The aim of the present study was to quantify (load per time interval) and qualify (gaseous vs. solid) cerebral microemboli (CME), detected as high-intensity transient signals, using transcranial Doppler ultrasound. MATERIALS AND METHODS Twenty intensive care unit (ICU group) patients requiring CVVHD were examined. CME were recorded in both middle cerebral arteries for 30 minutes during CVVHD and a CVVHD-free interval. Twenty additional patients, hospitalized for orthopedic surgery, served as a non-ICU control group. Statistical analyses were performed using the Mann-Whitney U test or the Wilcoxon matched-pairs signed-rank test, followed by Bonferroni corrections for multiple comparisons. RESULTS In the non-ICU group, 48 (14.5-169.5) (median [range]) gaseous CME were detected. In the ICU group, the 67.5 (14.5-588.5) gaseous CME detected during the CVVHD-free interval increased 5-fold to 344.5 (59-1019) during CVVHD (P<0.001). The number of solid CME was low in all groups (non-ICU group: 2 [0-5.5]; ICU group CVVHD-free interval: 1.5 [0-14.25]; ICU group during CVVHD: 7 [3-27.75]). CONCLUSIONS This observational pilot study shows that CVVHD was associated with a higher gaseous but not solid CME burden in critically ill patients. Although the differentiation between gaseous and solid CME remains challenging, our finding may support the hypothesis of microbubble generation in the CVVHD circuit and its transpulmonary translocation toward the intracranial circulation. Importantly, the impact of gaseous and solid CME generated during CVVHD on brain integrity of critically ill patients currently remains unknown and is highly debated.
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Wu C, Li C, Zhao W, Xie N, Yan F, Lian Y, Zhou L, Xu X, Liang Y, Wang L, Ren M, Li S, Cheng X, Zhang L, Ma Q, Song H, Meng R, Ji X. Elevated trimethylamine N-oxide related to ischemic brain lesions after carotid artery stenting. Neurology 2018. [PMID: 29540587 DOI: 10.1212/wnl.0000000000005298] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES To investigate whether the plasma level of trimethylamine N-oxide (TMAO), a proatherosclerotic intestinal microbiota metabolite, can be a predictor of ischemic brain injury secondary to carotid artery stenting (CAS). METHODS In this multicenter, prospective cohort study, we enrolled patients with severe carotid artery stenosis (>70%) who were prepared for CAS. Plasma TMAO level was measured within 3 days before CAS, and MRI was performed 1 to 3 days after CAS. RESULTS The mean age of the 268 eligible patients was 64.4 years. New lesions on diffusion-weighted imaging (DWI) were detected in 117 patients (43.7%). TMAO level was higher in patients with new (DWI) lesions than in patients without new lesions (median 5.2 vs 3.2 µmol/L; p < 0.001). Increased plasma TMAO levels were associated with an increased risk of having new lesions on DWI after CAS (adjusted odds ratio for the highest vs lowest quartile, 3.85; 95% confidence interval, 1.37-7.56, p < 0.001; adjusted odds ratio for the third vs lowest quartile, 1.86; 95% confidence interval, 1.09-4.66, p = 0.02). The area under the receiver operating characteristic curve of TMAO was 0.706 for new lesions on DWI, and the optimal cutoff value was 4.29 µmol/L. The sensitivity, specificity, positive predictive value, and negative predictive value of TMAO levels ≥4.29 µmol/L for predicting new lesions on DWI were 61.5%, 74.8%, 65.5%, and 65.5%, respectively. CONCLUSIONS Increased TMAO levels are associated with an increased risk of new ischemic brain lesions on post-CAS MRI scans.
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Affiliation(s)
- Chuanjie Wu
- From the Departments of Neurology (C.W., W.Z., M.R., Q.M., H.S., R.M.), Neurosurgery (C.L., F.Y., X.J.), and Emergency (S.L.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (N.X., Y. Lian, X.C., L. Zhang), The First Affiliated Hospital of Zhengzhou University; Department of Neurology (L. Zhou), Luzhou People's Hospital; Department of Neurology (X.X.), Zigong First People's Hospital; Department of Neurology (Y. Liang), Xiangtan Central Hospital; and Department of Neurology (L.W.), Guizhou Provincial People's Hospital, China
| | - Chuanhui Li
- From the Departments of Neurology (C.W., W.Z., M.R., Q.M., H.S., R.M.), Neurosurgery (C.L., F.Y., X.J.), and Emergency (S.L.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (N.X., Y. Lian, X.C., L. Zhang), The First Affiliated Hospital of Zhengzhou University; Department of Neurology (L. Zhou), Luzhou People's Hospital; Department of Neurology (X.X.), Zigong First People's Hospital; Department of Neurology (Y. Liang), Xiangtan Central Hospital; and Department of Neurology (L.W.), Guizhou Provincial People's Hospital, China
| | - Wenbo Zhao
- From the Departments of Neurology (C.W., W.Z., M.R., Q.M., H.S., R.M.), Neurosurgery (C.L., F.Y., X.J.), and Emergency (S.L.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (N.X., Y. Lian, X.C., L. Zhang), The First Affiliated Hospital of Zhengzhou University; Department of Neurology (L. Zhou), Luzhou People's Hospital; Department of Neurology (X.X.), Zigong First People's Hospital; Department of Neurology (Y. Liang), Xiangtan Central Hospital; and Department of Neurology (L.W.), Guizhou Provincial People's Hospital, China
| | - Nanchang Xie
- From the Departments of Neurology (C.W., W.Z., M.R., Q.M., H.S., R.M.), Neurosurgery (C.L., F.Y., X.J.), and Emergency (S.L.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (N.X., Y. Lian, X.C., L. Zhang), The First Affiliated Hospital of Zhengzhou University; Department of Neurology (L. Zhou), Luzhou People's Hospital; Department of Neurology (X.X.), Zigong First People's Hospital; Department of Neurology (Y. Liang), Xiangtan Central Hospital; and Department of Neurology (L.W.), Guizhou Provincial People's Hospital, China
| | - Feng Yan
- From the Departments of Neurology (C.W., W.Z., M.R., Q.M., H.S., R.M.), Neurosurgery (C.L., F.Y., X.J.), and Emergency (S.L.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (N.X., Y. Lian, X.C., L. Zhang), The First Affiliated Hospital of Zhengzhou University; Department of Neurology (L. Zhou), Luzhou People's Hospital; Department of Neurology (X.X.), Zigong First People's Hospital; Department of Neurology (Y. Liang), Xiangtan Central Hospital; and Department of Neurology (L.W.), Guizhou Provincial People's Hospital, China
| | - Yajun Lian
- From the Departments of Neurology (C.W., W.Z., M.R., Q.M., H.S., R.M.), Neurosurgery (C.L., F.Y., X.J.), and Emergency (S.L.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (N.X., Y. Lian, X.C., L. Zhang), The First Affiliated Hospital of Zhengzhou University; Department of Neurology (L. Zhou), Luzhou People's Hospital; Department of Neurology (X.X.), Zigong First People's Hospital; Department of Neurology (Y. Liang), Xiangtan Central Hospital; and Department of Neurology (L.W.), Guizhou Provincial People's Hospital, China
| | - Li Zhou
- From the Departments of Neurology (C.W., W.Z., M.R., Q.M., H.S., R.M.), Neurosurgery (C.L., F.Y., X.J.), and Emergency (S.L.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (N.X., Y. Lian, X.C., L. Zhang), The First Affiliated Hospital of Zhengzhou University; Department of Neurology (L. Zhou), Luzhou People's Hospital; Department of Neurology (X.X.), Zigong First People's Hospital; Department of Neurology (Y. Liang), Xiangtan Central Hospital; and Department of Neurology (L.W.), Guizhou Provincial People's Hospital, China
| | - Xiaoya Xu
- From the Departments of Neurology (C.W., W.Z., M.R., Q.M., H.S., R.M.), Neurosurgery (C.L., F.Y., X.J.), and Emergency (S.L.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (N.X., Y. Lian, X.C., L. Zhang), The First Affiliated Hospital of Zhengzhou University; Department of Neurology (L. Zhou), Luzhou People's Hospital; Department of Neurology (X.X.), Zigong First People's Hospital; Department of Neurology (Y. Liang), Xiangtan Central Hospital; and Department of Neurology (L.W.), Guizhou Provincial People's Hospital, China
| | - Yong Liang
- From the Departments of Neurology (C.W., W.Z., M.R., Q.M., H.S., R.M.), Neurosurgery (C.L., F.Y., X.J.), and Emergency (S.L.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (N.X., Y. Lian, X.C., L. Zhang), The First Affiliated Hospital of Zhengzhou University; Department of Neurology (L. Zhou), Luzhou People's Hospital; Department of Neurology (X.X.), Zigong First People's Hospital; Department of Neurology (Y. Liang), Xiangtan Central Hospital; and Department of Neurology (L.W.), Guizhou Provincial People's Hospital, China
| | - Lu Wang
- From the Departments of Neurology (C.W., W.Z., M.R., Q.M., H.S., R.M.), Neurosurgery (C.L., F.Y., X.J.), and Emergency (S.L.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (N.X., Y. Lian, X.C., L. Zhang), The First Affiliated Hospital of Zhengzhou University; Department of Neurology (L. Zhou), Luzhou People's Hospital; Department of Neurology (X.X.), Zigong First People's Hospital; Department of Neurology (Y. Liang), Xiangtan Central Hospital; and Department of Neurology (L.W.), Guizhou Provincial People's Hospital, China
| | - Ming Ren
- From the Departments of Neurology (C.W., W.Z., M.R., Q.M., H.S., R.M.), Neurosurgery (C.L., F.Y., X.J.), and Emergency (S.L.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (N.X., Y. Lian, X.C., L. Zhang), The First Affiliated Hospital of Zhengzhou University; Department of Neurology (L. Zhou), Luzhou People's Hospital; Department of Neurology (X.X.), Zigong First People's Hospital; Department of Neurology (Y. Liang), Xiangtan Central Hospital; and Department of Neurology (L.W.), Guizhou Provincial People's Hospital, China
| | - Sijie Li
- From the Departments of Neurology (C.W., W.Z., M.R., Q.M., H.S., R.M.), Neurosurgery (C.L., F.Y., X.J.), and Emergency (S.L.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (N.X., Y. Lian, X.C., L. Zhang), The First Affiliated Hospital of Zhengzhou University; Department of Neurology (L. Zhou), Luzhou People's Hospital; Department of Neurology (X.X.), Zigong First People's Hospital; Department of Neurology (Y. Liang), Xiangtan Central Hospital; and Department of Neurology (L.W.), Guizhou Provincial People's Hospital, China
| | - Xuan Cheng
- From the Departments of Neurology (C.W., W.Z., M.R., Q.M., H.S., R.M.), Neurosurgery (C.L., F.Y., X.J.), and Emergency (S.L.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (N.X., Y. Lian, X.C., L. Zhang), The First Affiliated Hospital of Zhengzhou University; Department of Neurology (L. Zhou), Luzhou People's Hospital; Department of Neurology (X.X.), Zigong First People's Hospital; Department of Neurology (Y. Liang), Xiangtan Central Hospital; and Department of Neurology (L.W.), Guizhou Provincial People's Hospital, China
| | - Lu Zhang
- From the Departments of Neurology (C.W., W.Z., M.R., Q.M., H.S., R.M.), Neurosurgery (C.L., F.Y., X.J.), and Emergency (S.L.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (N.X., Y. Lian, X.C., L. Zhang), The First Affiliated Hospital of Zhengzhou University; Department of Neurology (L. Zhou), Luzhou People's Hospital; Department of Neurology (X.X.), Zigong First People's Hospital; Department of Neurology (Y. Liang), Xiangtan Central Hospital; and Department of Neurology (L.W.), Guizhou Provincial People's Hospital, China
| | - Qingfeng Ma
- From the Departments of Neurology (C.W., W.Z., M.R., Q.M., H.S., R.M.), Neurosurgery (C.L., F.Y., X.J.), and Emergency (S.L.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (N.X., Y. Lian, X.C., L. Zhang), The First Affiliated Hospital of Zhengzhou University; Department of Neurology (L. Zhou), Luzhou People's Hospital; Department of Neurology (X.X.), Zigong First People's Hospital; Department of Neurology (Y. Liang), Xiangtan Central Hospital; and Department of Neurology (L.W.), Guizhou Provincial People's Hospital, China
| | - Haiqing Song
- From the Departments of Neurology (C.W., W.Z., M.R., Q.M., H.S., R.M.), Neurosurgery (C.L., F.Y., X.J.), and Emergency (S.L.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (N.X., Y. Lian, X.C., L. Zhang), The First Affiliated Hospital of Zhengzhou University; Department of Neurology (L. Zhou), Luzhou People's Hospital; Department of Neurology (X.X.), Zigong First People's Hospital; Department of Neurology (Y. Liang), Xiangtan Central Hospital; and Department of Neurology (L.W.), Guizhou Provincial People's Hospital, China
| | - Ran Meng
- From the Departments of Neurology (C.W., W.Z., M.R., Q.M., H.S., R.M.), Neurosurgery (C.L., F.Y., X.J.), and Emergency (S.L.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (N.X., Y. Lian, X.C., L. Zhang), The First Affiliated Hospital of Zhengzhou University; Department of Neurology (L. Zhou), Luzhou People's Hospital; Department of Neurology (X.X.), Zigong First People's Hospital; Department of Neurology (Y. Liang), Xiangtan Central Hospital; and Department of Neurology (L.W.), Guizhou Provincial People's Hospital, China
| | - Xunming Ji
- From the Departments of Neurology (C.W., W.Z., M.R., Q.M., H.S., R.M.), Neurosurgery (C.L., F.Y., X.J.), and Emergency (S.L.), Xuanwu Hospital Capital Medical University, Beijing; Department of Neurology (N.X., Y. Lian, X.C., L. Zhang), The First Affiliated Hospital of Zhengzhou University; Department of Neurology (L. Zhou), Luzhou People's Hospital; Department of Neurology (X.X.), Zigong First People's Hospital; Department of Neurology (Y. Liang), Xiangtan Central Hospital; and Department of Neurology (L.W.), Guizhou Provincial People's Hospital, China.
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20
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Abstract
There is a clear association between carotid artery stenosis and cognitive impairment. However, there is no consensus as to how to interpret this association, and what, if any, impact this connection should have on the management of carotid stenosis. A review of the relevant literature suggests that although an intervention to relieve carotid stenosis in patients without clinically significant cognitive impairment does not improve cognition, there may be a cognitive benefit with intervention for carotid stenosis in those patients with clinically significant cognitive disorders.
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21
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Kietaibl C, Engel A, Horvat Menih I, Huepfl M, Erdoes G, Kubista B, Ullrich R, Windhager R, Markstaller K, Klein K. Detection and differentiation of cerebral microemboli in patients undergoing major orthopaedic surgery using transcranial Doppler ultrasound. Br J Anaesth 2017; 118:400-406. [DOI: 10.1093/bja/aex001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2017] [Indexed: 01/28/2023] Open
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22
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Lee EJ, Cho YP, Lee SH, Lee JS, Nam HJ, Kim BJ, Kwon TW, Kang DW, Kim JS, Kwon SU. Hemodynamic Tandem Intracranial Lesions on Magnetic Resonance Angiography in Patients Undergoing Carotid Endarterectomy. J Am Heart Assoc 2016; 5:JAHA.116.004153. [PMID: 27702804 PMCID: PMC5121513 DOI: 10.1161/jaha.116.004153] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Hemodynamic tandem intracranial lesions (TILs) on intracranial magnetic resonance angiography, which develop flow dependently, have been overlooked clinically in patients undergoing carotid endarterectomy. As they represent severe baseline hemodynamic compromise at the segment, they may be associated with distinctive clinical outcomes. Methods and Results We assessed 304 consecutive carotid endarterectomy cases treated over 3 years. Included cases had both preoperative and postoperative intracranial 3‐dimensional time‐of‐flight magnetic resonance angiography, of which signal intensities are flow dependent, and postoperative diffusion‐weighted imaging (≤3 days following carotid endarterectomy). Preoperative TILs in the ipsilateral intracranial arteries were evaluated by the presence of nonexclusive components: focal stenosis (>50%), diffuse stenosis (>50%), and decreased signal intensities (>50%). The components showing postoperative normalization were considered hemodynamic. TILs with hemodynamic components were defined as hemodynamic TILs, while others as consistent TILs. Baseline characteristics and postoperative outcomes were analyzed among 3 groups: no TILs, consistent TILs, and hemodynamic TILs. Preoperative TILs were identified in 104 (34.2%) cases; 54 (17.8%) had hemodynamic components. Diffuse stenosis and decreased signal intensities were usually reversed postoperatively. Patients with hemodynamic TILs tended to have severe proximal carotid stenosis and recent strokes (≤14 days). For the outcome, hemodynamic TILs were independently associated with the advent of postoperative ischemic lesions on diffusion‐weighted imaging (odds ratio: 2.50; 95% CI, 1.20–5.20). Conclusions In patients undergoing carotid endarterectomy, a significant number of preoperative TILs demonstrated hemodynamic components, which were reversed postoperatively. The presence of such components was distinctively associated with the postoperative incidence of new ischemic lesions.
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Affiliation(s)
- Eun-Jae Lee
- Department of Neurology, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Yong-Pil Cho
- Department of Surgery, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Sang-Hun Lee
- Department of Neurology, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Hyo Jung Nam
- Department of Neurology, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Bum Joon Kim
- Department of Neurology, KyungHee University, Seoul, Korea
| | - Tae-Won Kwon
- Department of Surgery, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Dong-Wha Kang
- Department of Neurology, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Jong S Kim
- Department of Neurology, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Sun U Kwon
- Department of Neurology, Asan Medical Center, University of Ulsan, Seoul, Korea
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23
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Plessers M, Van Herzeele I, Hemelsoet D, Vingerhoets G, Vermassen F. Perioperative Embolization Load and S-100β Do Not Predict Cognitive Outcome after Carotid Revascularization. Ann Vasc Surg 2016; 36:175-181. [DOI: 10.1016/j.avsg.2016.02.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 02/19/2016] [Accepted: 02/23/2016] [Indexed: 11/27/2022]
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24
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Hitchner E, Baughman BD, Soman S, Long B, Rosen A, Zhou W. Microembolization is associated with transient cognitive decline in patients undergoing carotid interventions. J Vasc Surg 2016; 64:1719-1725. [PMID: 27633169 DOI: 10.1016/j.jvs.2016.06.104] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 06/14/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Carotid interventions are important in helping to reduce the risk of stroke for patients with high-grade carotid artery stenosis; however, subclinical cerebral microemboli can occur during these procedures. Associations have been found between the incidence of microemboli and postoperative decline in memory. We therefore sought to determine whether this decline persisted long-term and to assess changes in other cognitive domains. METHODS Patients were prospectively recruited under an Institutional Review Board-approved protocol at a single academic center. Neuropsychological testing was administered preoperatively and at 1-month and 6-month intervals postoperatively. Cognitive domains that were evaluated included verbal memory, visual memory, psychomotor speed, dexterity, and executive function. Diffusion-weighted magnetic resonance imaging sequencing was performed preoperatively and ≤48 hours postoperatively to identify procedure-related microemboli. Univariate and multivariate regression models were used to identify relationships among microembolization, demographics, and cognition. RESULTS Included were 80 male patients with an average age of 69 years. Forty patients underwent carotid artery stenting and 40 underwent carotid endarterectomy. Comorbidities included diabetes in 45%, coronary artery disease in 50%, and prior neurologic symptoms in 41%. New postoperative microemboli were found in 45 patients (56%). Microembolization was significantly more common in the carotid artery stenting cohort (P < .005). Univariate analysis demonstrated that patients with procedurally related embolization showed decline 1 month postoperatively in verbal memory and Trail Making A measures. Multivariate analysis demonstrated that procedurally related embolization (odds ratio [OR], 2.8; P = .04) and preoperative symptomatic stenosis (OR, 3.2; P = .026) were independent predictors of decline for the Rey Auditory Verbal Learning Test Short Delay measure at 1 month. At 6 months, no significant relationship was found between emboli and decline on Rey Auditory Verbal Learning Test Short Delay, but age (OR, 1.1, P = .005) and chronic obstructive pulmonary disease (OR, 7.1, P = .018) were significantly associated with decline at 6 months after the intervention. CONCLUSIONS Microembolization that is associated with carotid artery intervention predicts short-term cognitive decline. However, some of these cognitive deficits persist at 6 months after the intervention, and further investigation is warranted to determine individual patient risk factors that may affect recovery.
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Affiliation(s)
- Elizabeth Hitchner
- Division of Vascular Surgery, VA Palo Alto Health Care System, Palo Alto, Calif
| | | | - Salil Soman
- Department of Neuroradiology, Harvard School of Medicine, Cambridge, Mass
| | - Becky Long
- Division of Vascular Surgery, VA Palo Alto Health Care System, Palo Alto, Calif
| | - Allyson Rosen
- Division of Vascular Surgery, VA Palo Alto Health Care System, Palo Alto, Calif
| | - Wei Zhou
- Division of Vascular Surgery, VA Palo Alto Health Care System, Palo Alto, Calif; Division of Vascular Surgery, Stanford University, Stanford, Calif.
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25
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Wallace S, Døhlen G, Holmstrøm H, Lund C, Russell D. Cerebral Microemboli Detection and Differentiation During Transcatheter Closure of Patent Ductus Arteriosus. Pediatr Cardiol 2016; 37:1141-7. [PMID: 27229332 DOI: 10.1007/s00246-016-1410-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 05/17/2016] [Indexed: 10/21/2022]
Abstract
The aim of this prospective study was to determine the frequency and composition of cerebral microemboli in a pediatric population, during transcatheter closure of patent ductus arteriosus (PDA). Multifrequency transcranial Doppler was used to monitor cerebral blood flow velocity (CBFV) and detect microembolic signals (MES) in the middle cerebral artery in 23 patients (median age 18 months). MES were automatically identified and differentiated according to composition; gaseous or solid. The procedure was divided into five periods: Arterial catheterization; venous catheterization; ductal catheterization; angiography; device placement and release. Timing of catheter manipulations and MES were registered and compared. MES were detected in all patients. The median number of signals was 7, (minimum 1, maximum 28). Over 95 % of all MES were gaseous. 11 % were detected during device placement while 64 % were detected during angiographic studies, significantly higher than during any other period (P < 0.001). There was a moderate correlation between the number of MES and volume of contrast used, (R = 0.622, P < 0.01). There was no correlation with fluoroscopic time or duration of procedure. This is the first study to investigate the timing and composition of cerebral microemboli during PDA occlusion. Microemboli were related to specific catheter manipulations and correlated with the amount of contrast used.
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Affiliation(s)
- Sean Wallace
- Department of Paediatric Cardiology, Rikshospitalet, Oslo, Norway.
| | - Gaute Døhlen
- Department of Paediatric Cardiology, Rikshospitalet, Oslo, Norway
| | - Henrik Holmstrøm
- Department of Paediatric Cardiology, Rikshospitalet, Oslo, Norway
| | | | - David Russell
- Department of Neurology, Rikshospitalet, Oslo, Norway
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26
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D’Andrea A, Conte M, Cavallaro M, Scarafile R, Riegler L, Cocchia R, Pezzullo E, Carbone A, Natale F, Santoro G, Caso P, Russo MG, Bossone E, Calabrò R. Transcranial Doppler ultrasonography: From methodology to major clinical applications. World J Cardiol 2016; 8:383-400. [PMID: 27468332 PMCID: PMC4958690 DOI: 10.4330/wjc.v8.i7.383] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 04/22/2016] [Accepted: 05/27/2016] [Indexed: 02/06/2023] Open
Abstract
Non-invasive Doppler ultrasonographic study of cerebral arteries [transcranial Doppler (TCD)] has been extensively applied on both outpatient and inpatient settings. It is performed placing a low-frequency (≤ 2 MHz) transducer on the scalp of the patient over specific acoustic windows, in order to visualize the intracranial arterial vessels and to evaluate the cerebral blood flow velocity and its alteration in many different conditions. Nowadays the most widespread indication for TCD in outpatient setting is the research of right to left shunting, responsable of so called “paradoxical embolism”, most often due to patency of foramen ovale which is responsable of the majority of cryptogenic strokes occuring in patients younger than 55 years old. TCD also allows to classify the grade of severity of such shunts using the so called “microembolic signal grading score”. In addition TCD has found many useful applications in neurocritical care practice. It is useful on both adults and children for day-to-day bedside assessment of critical conditions including vasospasm in subarachnoidal haemorrhage (caused by aneurysm rupture or traumatic injury), traumatic brain injury, brain stem death. It is used also to evaluate cerebral hemodynamic changes after stroke. It also allows to investigate cerebral pressure autoregulation and for the clinical evaluation of cerebral autoregulatory reserve.
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27
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Olveira GDP, Guillaumon AT, Benvindo SC, Lima JMT, Barreto SRF, Avelar WM, Cendes F. A comparative analysis of transcranial Doppler parameters acquired during carotid stenting and semi-eversion carotid endarterectomy. J Vasc Bras 2016; 15:197-204. [PMID: 29930590 PMCID: PMC5829756 DOI: 10.1590/1677-5449.003316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Carotid endarterectomy (CEA) and carotid artery stenting (CAS) have both been proposed for treatment of critical atherosclerotic stenosis located at the carotid bifurcation. Monitoring of hyperintense microembolic signals (MES) by transcranial Doppler ultrasound (TCD) is considered a method of quality control, both in CEA and in CAS. Objective To analyze temporal distribution of MES throughout both semi-eversion CEA and CAS procedures and to evaluate changes in mean velocity of blood flow through the ipsilateral middle cerebral artery (MCA). Method Thirty-three procedures (17 CEA and 16 CAS) were prospectively monitored using TCD and the data were related to three different stages of surgery (pre-cerebral protection, during cerebral protection and post-cerebral protection). Chi-square, Mann-Whitney, ANOVA and contrast tests were used for statistical analysis. Results The MES were uniformly distributed in the CEA group, but not in the CAS group (p = 0.208). The number of MES was higher in the CAS group in all stages. The average flow in the MCA was similarly lower in both groups during the protection stage. Conclusion CEA provoked a lower incidence of MES per procedure than CAS in all stages. The behavior of the averages of the mean of blood flow through the MCA was similar in both groups.
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Affiliation(s)
- Germano da Paz Olveira
- Universidade Estadual de Campinas - UNICAMP, Departamento de Cirurgia, Campinas, SP, Brazil
| | | | | | | | | | - Wagner Mauad Avelar
- Universidade Estadual de Campinas - UNICAMP, Departamento de Neurologia, Campinas, SP, Brazil
| | - Fernando Cendes
- Universidade Estadual de Campinas - UNICAMP, Departamento de Neurologia, Campinas, SP, Brazil
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28
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Li J, Shalabi A, Ji F, Meng L. Monitoring cerebral ischemia during carotid endarterectomy and stenting. J Biomed Res 2016; 31. [PMID: 27231044 PMCID: PMC5274507 DOI: 10.7555/jbr.31.20150171] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Accepted: 02/02/2016] [Indexed: 11/03/2022] Open
Abstract
Current therapy for carotid stenosis mainly includes carotid endarterectomy and endovascular stenting, which may incur procedure-related cerebral ischemia. Several methods have been employed for monitoring cerebral ischemia during surgery, such as awake neurocognitive assessment, electroencephalography, evoked potentials, transcranial Doppler, carotid stump pressure, and near infrared spectroscopy. However, there is no consensus on the gold standard or the method that is superior to others at present. Keeping patient awake for real time neurocognitive assessment is effective and essential; however, not every surgeon adopts it. In patients under general anesthesia, cerebral ischemia monitoring has to rely on non-awake technologies. The advantageous and disadvantageous properties of each monitoring method are reviewed.
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Affiliation(s)
- Jian Li
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, China
| | - Ahmed Shalabi
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA 94143, USA
| | - Fuhai Ji
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, China
| | - Lingzhong Meng
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA 94143, USA.
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29
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Bourke V, Bourke B, Beiles C. Operative Factors Associated with the Development of New Brain Lesions During Awake Carotid Endarterectomy. Eur J Vasc Endovasc Surg 2016; 51:167-73. [DOI: 10.1016/j.ejvs.2015.08.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 08/26/2015] [Indexed: 11/28/2022]
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30
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Plessers M, Van Herzeele I, Hemelsoet D, Patel N, Chung EML, Vingerhoets G, Vermassen F. Transcervical Carotid Stenting With Dynamic Flow Reversal Demonstrates Embolization Rates Comparable to Carotid Endarterectomy. J Endovasc Ther 2016; 23:249-54. [PMID: 26794908 DOI: 10.1177/1526602815626561] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE To evaluate a series of patients treated electively with carotid endarterectomy (CEA), transfemoral carotid artery stenting with distal filter protection (CASdp), and transcervical carotid stenting with dynamic flow reversal (CASfr) monitored continuously with transcranial Doppler (TCD) during the procedure to detect intraoperative embolization rates. METHODS Thirty-four patients (mean age 67.6 years; 24 men) with significant carotid stenosis underwent successful TCD monitoring during the revascularization procedure (10 CEA, 8 CASdp, and 16 CASfr). Ipsilateral microembolic signals were segregated into 3 phases: preprotection (until internal carotid artery cross-shunted or clamped if no shunt was used, filter deployed, or flow reversal established), protection (until clamp/shunt was removed, filter retrieved, or antegrade flow reestablished), and postprotection (after clamp/shunt or filter removal or restoration of normal flow). RESULTS CASdp showed higher embolization rates than CEA or CASfr in the preprotection phase (p<0.001). In the protection phase, CASdp was again associated with more embolization compared with CEA and CASfr (p<0.001). In the postprotection phase, no differences between the revascularization therapies were observed. CASfr and CEA did not show significant differences in intraoperative embolization during any of the phases. CONCLUSION TCD recordings demonstrated a significant reduction in embolization to the brain during transcervical carotid artery stent placement with the use of dynamic flow reversal compared to transfemoral CAS using distal filters. No significant differences in microembolization could be detected between CEA and CASfr. The observed lower embolization rates and lack of adverse events suggest that transcervical CAS with dynamic flow reversal is a promising technique and may be the preferred method when performing CAS.
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Affiliation(s)
- Maarten Plessers
- Department of Experimental Psychology, Ghent University, Ghent, Belgium Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Isabelle Van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | | | - Nikil Patel
- Department of Cardiovascular Sciences, University of Leicester, UK
| | - Emma M L Chung
- Department of Cardiovascular Sciences, University of Leicester, UK
| | - Guy Vingerhoets
- Department of Experimental Psychology, Ghent University, Ghent, Belgium
| | - Frank Vermassen
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
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31
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Williamson RW, Spetzler RF. Carotid Endarterectomy Is Safe, Effective, and Durable, but Can We Make It Better? World Neurosurg 2016; 90:625-626. [PMID: 26752091 DOI: 10.1016/j.wneu.2015.12.087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 12/26/2015] [Indexed: 11/18/2022]
Affiliation(s)
- Richard W Williamson
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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32
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D'Andrea A, Conte M, Scarafile R, Riegler L, Cocchia R, Pezzullo E, Cavallaro M, Carbone A, Natale F, Russo MG, Gregorio G, Calabrò R. Transcranial Doppler Ultrasound: Physical Principles and Principal Applications in Neurocritical Care Unit. J Cardiovasc Echogr 2016; 26:28-41. [PMID: 28465958 PMCID: PMC5224659 DOI: 10.4103/2211-4122.183746] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Transcranial Doppler (TCD) ultrasonography is a noninvasive ultrasound study, which has been extensively applied on both outpatient and inpatient settings. It involves the use of a low-frequency (≤2 MHz) transducer, placed on the scalp, to insonate the basal cerebral arteries through relatively thin bone windows and to measure the cerebral blood flow velocity and its alteration in many different conditions. In neurointensive care setting, TCD is useful for both adults and children for day-to-day bedside assessment of critical conditions including vasospasm in subarachnoid hemorrhage, traumatic brain injury, acute ischemic stroke, and brain stem death. It also allows to investigate the cerebrovascular autoregulation in setting of carotid disease and syncope. In this review, we will describe physical principles underlying TCD, flow indices most frequently used in clinical practice and critical care applications in Neurocritical Unit care.
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Affiliation(s)
- Antonello D'Andrea
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Marianna Conte
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Raffaella Scarafile
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Lucia Riegler
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Rosangela Cocchia
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Enrica Pezzullo
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Massimo Cavallaro
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Andreina Carbone
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Francesco Natale
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Maria Giovanna Russo
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Giovanni Gregorio
- Department of Cardiology, San Luca Hospital, Vallo della Lucania, Salerno, Italy
| | - Raffaele Calabrò
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
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Małowidzka-Serwińska M, Żabicka M, Witkowski A, Chmielak Z, Deptuch T. Brain perfusion evaluated by perfusion-weighted magnetic resonance imaging before and after stenting internal carotid artery stenosis in asymptomatic and symptomatic patients. Neurol Neurochir Pol 2015; 49:412-20. [PMID: 26652876 DOI: 10.1016/j.pjnns.2015.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 07/31/2015] [Accepted: 10/12/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE To evaluate the brain perfusion with MRI perfusion weighted imaging (PWI) before and after ICA stenting in asymptomatic and symptomatic patients. MATERIALS AND METHODS PWI was performed 3-21 days before and 3 days after ICA stenting in 31 asymptomatic patients with ICA >70% stenosis - Group I, and in 14 symptomatic patients with ICA >50% stenosis - Group II. PWI was evaluated qualitatively and quantitatively in 5 cerebral territories with: mean transit time (MTT), cerebral blood volume (CBV) and cerebral blood flow (CBF). Mean values of perfusion parameters were measured before and after stenting ΔMTT, ΔCBV, ΔCBF were calculated as subtraction of after-treatment values from those before treatment. RESULTS In qualitative evaluation after ICA stenting perfusion was normalized in 21 patients (80.8%) in Group I and in 8 patients (80%) in Group II. In quantitative estimation MTT decreased significantly after CAS on stented side vs. non-stented side in all examined patients regardless of the group, p<0.05. MTT decreased more in Group II than in Group I in all territories (p<0.05) with the exception of temporal lobe. CBV and CBF have shown insignificant differences.
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Affiliation(s)
| | - Magdalena Żabicka
- Department of Radiology, Military Institute of Medicine, Warsaw, Poland
| | - Adam Witkowski
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | - Zbigniew Chmielak
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | - Tomasz Deptuch
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
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New cerebral lesions at magnetic resonance imaging after carotid artery stenting versus endarterectomy: an updated meta-analysis. PLoS One 2015; 10:e0129209. [PMID: 26017678 PMCID: PMC4446340 DOI: 10.1371/journal.pone.0129209] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Accepted: 05/07/2015] [Indexed: 11/20/2022] Open
Abstract
Background Carotid endarterectomy (CEA) or stenting (CAS) are associated with a relatively low rate of clinical events, but diffusion-weighted imaging (DWI) is increasingly being used to compare the incidence of new ischemic lesions. Therefore, we conducted an updated meta-analysis on the occurrence of post-procedural new DWI lesions after CAS versus CEA. Methods and Results MEDLINE, Cochrane, ISI Web of Science and SCOPUS databases were searched and 20 studies (2 randomized and 18 non-randomized) with a total of 2104 procedures (CAS = 989; CEA = 1115) were included. The incidence of new DWI cerebral lesions was significantly greater after CAS than CEA (40.3% vs 12.2%; 20 studies; 2104 patients; odds ratio [OR] 5.17; 95% confidence interval [CI], 3.31-8.06; p<0.00001). Also peri-procedural stroke (17 studies; 1833 patients; OR 2.01; 95% CI, 1.14-3.55; p=0.02) and stroke or TIA (17 studies; 1833 patients; OR 2.40; 95% CI, 1.42-4.08; p=0.001) were significantly increased after CAS. This latter clinical advantage in the CEA group over CAS was tempered when CEA procedures were performed with shunting in all instead of selective shunting or when CAS was performed with only closed cell stents instead of both closed and open cell stents, however, no significant differences between subgroups emerged. Conclusions CAS is associated with an increased incidence of post-procedural brain DWI lesions. This greater amount of ischemic burden may also reflect a higher rate of cerebral events after CAS. However, whether recent technical advances mainly for CAS could potentially reduce these ischemic events still remains to be evaluated.
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Cerebral microemboli detection and differentiation during transcatheter closure of atrial septal defect in a paediatric population. Cardiol Young 2015; 25:237-44. [PMID: 24522121 DOI: 10.1017/s1047951113002072] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION The aim of this prospective study was to determine the frequency and composition of cerebral microemboli in a paediatric population during transcatheter atrial septal defect closure. METHODS Multi-frequency transcranial Doppler was used to detect microembolic signals in the middle cerebral artery of 24 patients. Embolic signals were automatically identified and differentiated according to their composition, gaseous or solid. The procedure was divided into five periods: right cardiac catheterisation; left cardiac catheterisation; pulmonary angiography; balloon sizing; and device placement. RESULTS Microemboli were detected in all patients. The median number of signals was 63 and over 95% gaseous. The total number of microembolic signals detected during two periods - balloon sizing and sheath placement and device placement - was not significantly different (median: 18 and 25, respectively) but was significantly higher than each of the other three periods (p<0.001). In eight patients, the device was opened more than once and the number of embolic signals decreased with each successive device deployment. There was no correlation between the number of microembolic signals and fluoroscopic time, duration of procedure, age, or device size. CONCLUSION This is the first study to investigate the timing and composition of cerebral microemboli in a paediatric population during cardiac catheterisation. Microembolic signals were related to specific catheter manipulations but were not associated with fluoroscopic time or duration of procedure.
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Avoiding Complications After Carotid Endarterectomy. World Neurosurg 2014; 82:e699-700. [DOI: 10.1016/j.wneu.2013.09.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 09/23/2013] [Indexed: 11/22/2022]
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Iadecola C. Angiophagy: clearing or clogging microvessels? Sci Transl Med 2014; 6:226fs10. [PMID: 24598587 DOI: 10.1126/scitranslmed.3008667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The body clears small clots from blood vessels through a process called angiophagy, opening up new approaches to combat cerebral and cardiac microvascular occlusive diseases (Grutzendler et al., this issue).
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Affiliation(s)
- Costantino Iadecola
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY 10021, USA
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Kwon OS, Lee HJ, Kim WS, Hong JM, Cho HJ. Risk of continuing planned surgery after endovascular repair of subclavian artery injury: a case report. Korean J Anesthesiol 2014; 67:139-43. [PMID: 25237452 PMCID: PMC4166387 DOI: 10.4097/kjae.2014.67.2.139] [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: 11/05/2013] [Revised: 01/05/2014] [Accepted: 01/05/2014] [Indexed: 11/10/2022] Open
Abstract
Endovascular repair with covered stents has been widely used to treat subclavian and axillary artery injuries and has produced promising early results. The possibility of a thromboembolism occurring in cerebral arteries during an endovascular procedure should be a cause for concern. In the case of endovascular management of arterial traumas, a prompt and sufficient period for check-up of the patient's neurological signs is needed, even if it requires postponing elective intervention for the patient's safety. We report a rare case of liver transplantation immediately after endovascular repair of an iatrogenic subclavian arterial injury to describe the risk of continuing planned surgery without neurologic assessment.
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Affiliation(s)
- O-Sun Kwon
- Department of Anesthesia and Pain Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Hyeon Jeong Lee
- Department of Anesthesia and Pain Medicine, Pusan National University School of Medicine, Busan, Korea. ; Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Won-Sung Kim
- Department of Anesthesia and Pain Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Jung-Min Hong
- Department of Anesthesia and Pain Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Hyun-Jun Cho
- Department of Anesthesia and Pain Medicine, Pusan National University School of Medicine, Busan, Korea
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Shimamura N, Kikkawa T, Hatanaka M, Naraoka M, Munakata A, Ohkuma H. Dilation of the Internal Carotid Artery at the Entrance to the Carotid Canal following Carotid Artery Stenting Predicts Postprocedural Hyperperfusion. INTERVENTIONAL NEUROLOGY 2014; 2:1-7. [PMID: 25187780 DOI: 10.1159/000354289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Ischemic stroke and hyperperfusion (HP) are the most frequent and important complications in carotid artery stenosis surgery. Carotid artery stenting (CAS) has replaced carotid endarterectomy in high medical risk patients. Prior to CAS, initial angiographic findings disclose a small caliber internal carotid artery (IC) due to stenosis, but after the stenosis is relieved, the diameter of the IC becomes enlarged. We investigated whether a change in the IC diameter was related to ischemic complication and HP using cerebral blood flow single photon emission computed tomography (SPECT). METHODS From February 2008 to December 2009 we consecutively performed 39 CAS on 35 patients. We retrospectively analyzed the relationship between changes at the level before the entry to the petrous bone canal of the IC and stenosis of the etiological artery, improvement in stenosis, HP and postintervention diffusion-weighted image high-intensity lesions. Statistical analyses comprised Wilcoxon/Kruskal-Wallis analysis, analysis of variance and a multivariate logistic analysis. RESULTS A total of 9 cases showed HP in SPECT. Severity of IC stenosis and change in the IC at the level before the entry to the petrous bone canal were related with statistical significance to HP. Other factors did not correlate with HP. CONCLUSION Procedure-related dilation of the IC at the level before the entry to the petrous bone canal occurred due to release of the etiological stenosis. This finding can also support the prediction of HP.
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Affiliation(s)
- Norihito Shimamura
- Department of Neurosurgery, Hirosaki University School of Medicine, Hirosaki, Towada, Japan
| | - Tomoshige Kikkawa
- Department of Neurosurgery, Kuroishi Hospital, Kuroishi, Towada, Japan
| | | | - Masato Naraoka
- Department of Neurosurgery, Hirosaki University School of Medicine, Hirosaki, Towada, Japan
| | - Akira Munakata
- Department of Neurosurgery, Hirosaki University School of Medicine, Hirosaki, Towada, Japan
| | - Hiroki Ohkuma
- Department of Neurosurgery, Hirosaki University School of Medicine, Hirosaki, Towada, Japan
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Koyanagi M, Yoshida K, Kurosaki Y, Sadamasa N, Narumi O, Sato T, Chin M, Handa A, Yamagata S, Miyamoto S. Reduced cerebrovascular reserve is associated with an increased risk of postoperative ischemic lesions during carotid artery stenting. J Neurointerv Surg 2014; 8:576-80. [DOI: 10.1136/neurintsurg-2014-011163] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Accepted: 08/19/2014] [Indexed: 11/04/2022]
Abstract
BackgroundReduced cerebrovascular reserve (CVR) is associated with increased risk of ischemic events in carotid steno-occlusive diseases.ObjectiveTo determine whether pretreatment CVR can predict postoperative ischemic lesions after carotid artery stenting (CAS) by retrospective analysis.MethodsWe retrospectively reviewed the medical records of 46 patients (42 men; mean age 74.2±8.3 years) who underwent CAS and preprocedural cerebral blood flow measurement by quantitative single-photon emission CT. Ischemic lesions were evaluated by diffusion-weighted image (DWI) within 72 h after the intervention. We also evaluated plaque characteristics using black-blood MR plaque imaging.ResultsNew ipsilateral DWI-positive lesions were found in 11 cases (23.9%). Patients were classified into two groups based on the presence or absence of new DWI-positive lesions, and no significant differences in characteristics were found between the DWI-positive and DWI-negative groups, except for age and CVR of the ipsilateral middle cerebral artery (MCA) territory. The DWI-positive group was significantly older than the DWI-negative group (79.7±4.1 vs 72.5±8.6 years; p=0.0085) and had lower average regional CVR (1.4±18.2% vs 22.4±25.8%; p=0.016). MR plaque imaging showed no significant difference in relative overall plaque MR signal intensity between the two groups (1.53±0.37 vs 1.34±0.26; p=0.113). In multivariate logistic regression analysis, lower CVR of the ipsilateral MCA territory (<11%) was the only independent risk factor for new ischemic lesions following CAS (OR=6.99; 95% CI 1.17 to 41.80; p=0.033).ConclusionsImpaired pretreatment CVR was associated with increased incidence of new infarction after CAS.
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Cortese B, De Carlo M, De Matteis S, Rizza A, Giannini D, Palmieri C, Petronio AS, Berti S, Balbarini A, Ramee S. Distal embolisation during carotid stenting is predicted by circulating levels of LDL cholesterol and C-reactive protein. EUROINTERVENTION 2014; 10:513-517. [DOI: 10.4244/eijv10i4a88] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Terlecki P, Pawlik P, Iwaniuk A, Kocki T, Przywara S, Ilzecki M, Zubilewicz T, Kowalczyk M, Parada-Turska J, Dąbrowski W. Carotid surgery affects plasma kynurenic acid concentration: a pilot study. Med Sci Monit 2014; 20:303-10. [PMID: 24561546 PMCID: PMC3937007 DOI: 10.12659/msm.890212] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 01/06/2014] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND An increase in plasma kynurenic acid (KYNA) concentration has been observed following surgery, inflammation, and cerebral pathologies. The aim of the present study was to analyze the changes in plasma KYNA concentration in patients undergoing carotid surgery (CS). MATERIAL AND METHODS Adult patients undergoing elective carotid endarterectomy (CEA) or carotid angioplasty with stent placement (CAS) were studied. Plasma KYNA concentrations were analyzed before surgery and at 4 time points after CS. The amount of inflammation was measured as neutrophil-lymphocyte ratio (NLR). RESULTS Forty patients (10 female and 30 male) aged 55-86 years of age were evaluated in this study. In patients with unstable carotid plaque, the plasma KYNA concentration was higher than in patients with stable carotid plaque. Moreover, the NLR was significantly higher in patients with unstable carotid plaque undergoing CEA than in patients undergoing CAS. Plasma KYNA concentration increased after surgery in patients undergoing CEA and CAS. There was a strong correlation between plasma KYNA concentration and NLR in patients with postoperative neurological disorders. CONCLUSIONS CS increases plasma KYNA concentration, and changes in plasma KYNA concentration can indicate neurologic outcomes in patients undergoing CS.
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Affiliation(s)
- Piotr Terlecki
- Department of Vascular Surgery and Angiology Medical University of Lublin, Lublin, Poland
| | - Paulina Pawlik
- Department of Anesthesiology and Intensive Therapy Medical University of Lublin, Lublin, Poland
| | - Adam Iwaniuk
- Department of Clinical and Experimental Pharmacology Medical University of Lublin, Lublin, Poland
| | - Tomasz Kocki
- Department of Clinical and Experimental Pharmacology Medical University of Lublin, Lublin, Poland
| | - Stanisław Przywara
- Department of Vascular Surgery and Angiology Medical University of Lublin, Lublin, Poland
| | - Marek Ilzecki
- Department of Vascular Surgery and Angiology Medical University of Lublin, Lublin, Poland
| | - Tomasz Zubilewicz
- Department of Vascular Surgery and Angiology Medical University of Lublin, Lublin, Poland
| | - Michał Kowalczyk
- Department of Anesthesiology and Intensive Therapy Medical University of Lublin, Lublin, Poland
| | - Jolanta Parada-Turska
- Department of Rheumatology and Connective Tissue Diseases Medical University of Lublin, Lublin, Poland
| | - Wojciech Dąbrowski
- Department of Anesthesiology and Intensive Therapy Medical University of Lublin, Lublin, Poland
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Naqvi J, Yap KH, Ahmad G, Ghosh J. Transcranial Doppler ultrasound: a review of the physical principles and major applications in critical care. Int J Vasc Med 2013; 2013:629378. [PMID: 24455270 PMCID: PMC3876587 DOI: 10.1155/2013/629378] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 11/10/2013] [Indexed: 12/28/2022] Open
Abstract
Transcranial Doppler (TCD) is a noninvasive ultrasound (US) study used to measure cerebral blood flow velocity (CBF-V) in the major intracranial arteries. It involves use of low-frequency (≤2 MHz) US waves to insonate the basal cerebral arteries through relatively thin bone windows. TCD allows dynamic monitoring of CBF-V and vessel pulsatility, with a high temporal resolution. It is relatively inexpensive, repeatable, and portable. However, the performance of TCD is highly operator dependent and can be difficult, with approximately 10-20% of patients having inadequate transtemporal acoustic windows. Current applications of TCD include vasospasm in sickle cell disease, subarachnoid haemorrhage (SAH), and intra- and extracranial arterial stenosis and occlusion. TCD is also used in brain stem death, head injury, raised intracranial pressure (ICP), intraoperative monitoring, cerebral microembolism, and autoregulatory testing.
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Affiliation(s)
- Jawad Naqvi
- University Hospital South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
| | - Kok Hooi Yap
- Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
| | - Gulraiz Ahmad
- Royal Oldham Hospital, Rochdale Road, Manchester OL1 2JH, UK
| | - Jonathan Ghosh
- University Hospital South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
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Altinbas A, Algra A, Bonati LH, Brown MM, Kappelle LJ, de Borst GJ, Hendrikse J, van der Tweel I, van der Worp HB. Periprocedural hemodynamic depression is associated with a higher number of new ischemic brain lesions after stenting in the International Carotid Stenting Study-MRI Substudy. Stroke 2013; 45:146-51. [PMID: 24203845 DOI: 10.1161/strokeaha.113.003397] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Carotid artery stenting (CAS) is associated with a higher risk of both hemodynamic depression and new ischemic brain lesions on diffusion-weighted imaging than carotid endarterectomy (CEA). We assessed whether the occurrence of hemodynamic depression is associated with these lesions in patients with symptomatic carotid stenosis treated by CAS or CEA in the randomized International Carotid Stenting Study (ICSS)-MRI substudy. METHODS The number and total volume of new ischemic lesions on diffusion-weighted imaging 1 to 3 days after CAS or CEA was measured in the ICSS-MRI substudy. Hemodynamic depression was defined as periprocedural bradycardia, asystole, or hypotension requiring treatment. The number of new ischemic lesions was the primary outcome measure. We calculated risk ratios and 95% confidence intervals per treatment with Poisson regression comparing the number of lesions in patients with or without hemodynamic depression. RESULTS A total of 229 patients were included (122 allocated CAS; 107 CEA). After CAS, patients with hemodynamic depression had a mean of 13 new diffusion-weighted imaging lesions, compared with a mean of 4 in those without hemodynamic depression (risk ratio, 3.36; 95% confidence interval, 1.73-6.50). The number of lesions after CEA was too small for reliable analysis. Lesion volumes did not differ between patients with or without hemodynamic depression. CONCLUSIONS In patients treated by CAS, periprocedural hemodynamic depression is associated with an excess of new ischemic lesions on diffusion-weighted imaging. The findings support the hypothesis that hypoperfusion increases the susceptibility of the brain to embolism. CLINICAL TRIAL REGISTRATION URL: http://www.controlled-trials.com. Unique identifier: ISRCTN25337470.
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Affiliation(s)
- Aysun Altinbas
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (A. Altinbas, A. Algra, L.J.K., H.B.v.d.W.), Julius Center for Health Sciences and Primary Care (A. Algra, I.v.d.T.), Department of Vascular Surgery (G.J.d.B.), and Department of Radiology (J.H.), University Medical Center Utrecht, Utrecht, The Netherlands; Department of Brain Repair and Rehabilitation, Institute of Neurology, University College London, London, United Kingdom (L.H.B., M.M.B.); and Department of Neurology and Stroke Unit, University Hospital Basel, Basel, Switzerland (L.H.B.)
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Stratification of intraoperative ischemic impact by somatosensory evoked potential monitoring, diffusion-weighted imaging and magnetic resonance angiography in carotid endarterectomy with routine shunt use. Acta Neurochir (Wien) 2013; 155:2085-96. [PMID: 23996165 DOI: 10.1007/s00701-013-1858-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Accepted: 08/20/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Routine shunting to minimize ischemia during carotid endarterectomy (CEA) is controversial. The aim of this study was to stratify the ischemic parameters associated with CEA and evaluate the effect of routine shunting in attempting to mitigate those ischemia. METHOD Data from 248 CEAs with routine shunting were retrospectively evaluated. Our assessment included somatosensory evoked potential (SSEP) amplitude reduction more than 50 % and longer than 5 min (SSEP<50%, >5 min), new postoperative diffusion-weighted imaging lesions (new DWI lesions), and severe stenosis as indicated by reduced ipsilateral middle cerebral artery (MCA) signal on preoperative magnetic resonance angiography (MRA asymmetry), as surrogates of hypoperfusion, microembli, and hemodynamic impairment, respectively. RESULTS SSEP<50%, >5 min occurred in 15 % of CEAs during cross-clamping, and shunting reversed the SSEP changes. New DWI lesions were observed in 4.1 %. Pre-clamping the common and external carotid artery during dissection (pre-clamp method) decreased the rate of new DWI lesions compared to without pre-clamping (3.5 % vs. 7.5 %, P = 0.22). Occlusion time was significantly longer in the pre-clamp method than without pre-clamping (P < 0.0001). However, the incidence of SSEP<50%, >5 min was not increased with the pre-clamp method (p = 1.0) when using information regarding SSEP and collaterals to modify the speed of shunt manipulation. MRA asymmetry was identified in 39 CEAs (15.8 %) with correction of asymmetry postoperatively. MRA asymmetry correlated with symptomatic hyperperfusion (P = 0.0034). Only three CEAs had symptomatic hyperperfusion (1.2 %) with minimal symptoms. Ten CEAs sustained transient ischemia, symptomatic hyperperfusion, or 30-day-stroke (composite postoperative ischemic symptoms). Logistic regression analysis confirmed that SSEP<50%, >5 min (p = 0.009), new DWI lesions (p = 0.004) and MRA asymmetry (p = 0.042) were independent predictors of composite postoperative ischemic symptoms. CONCLUSIONS SSEP<50%, >5 min, new DWI lesions, and MRA asymmetry were able to stratify the ischemic impacts in CEA. Meticulous routine shunting could mitigate those appropriately.
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Castro-Afonso LHD, Abud LG, Rolo JG, Santos ACD, Oliveira LD, Barreira CMA, Velasco TR, Pontes-Neto OM, Abud DG. Flow reversal versus filter protection: a pilot carotid artery stenting randomized trial. Circ Cardiovasc Interv 2013; 6:552-9. [PMID: 24084627 DOI: 10.1161/circinterventions.113.000479] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Carotid artery stenting (CAS) has become an alternative treatment for patients presenting symptomatic carotid artery stenosis. The improvement in clinical outcomes with CAS has been associated with the development of embolic protection devices. The trial aim is to compare flow reversal versus filter protection during CAS through femoral access. METHODS AND RESULTS Patients were randomly enrolled in CAS using flow reversal or filter protection. The primary end points were the incidence, number, and size of new ischemic brain lesions after CAS. The secondary end points included major adverse cardiac and cerebrovascular events, transient ischemic attack, and definitive ischemic brain lesions on fluid-attenuated inversion recovery magnetic resonance image at a 3-month follow-up. Ischemic brain lesions were assessed by a 3T magnetic resonance image. Neurological outcomes were evaluated by means of the National Institutes of Health Stroke Scale and the modified Rankin Scale (mRS). Forty consecutive patients were randomly assigned. Compared with flow reversal (n=21), filter protection (n=19) resulted in a significant reduction in the incidence (15.8% versus 47.6%, P=0.03), number (0.73 versus 2.6, P=0.05), and size (0.81 versus 2.23 mm, P=0.05) of new ischemic brain lesions. Two patients, 1 from each group, presented transient ischemic attack at 3-month follow-up. There were no major adverse cardiac and cerebrovascular events in the hospital or at 3-month follow-up. CONCLUSIONS In this small sample size trial, filter protection was more effective than flow reversal in reducing ischemic brain lesions during CAS through femoral approach. CLINICAL TRIAL REGISTRATION URL http://portal2.saude.gov.br/sisnep/. Unique identifier: 0538.0.004.000-10.
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Affiliation(s)
- Luis Henrique de Castro-Afonso
- Division of Interventional Neuroradiology, Division of Neuroradiology, and Division of Neurology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
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Topcuoglu MA, Unal A, Arsava EM. Advances in transcranial Doppler clinical applications. ACTA ACUST UNITED AC 2013; 4:343-58. [PMID: 23496150 DOI: 10.1517/17530059.2010.495749] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
IMPORTANCE OF THE FIELD Diagnostic neurosonology techniques including transcranial Doppler (TCD), transcranial color Doppler imaging (TCDI) and power motion-mode (PMD) TCD provide information about various aspects of cerebrovascular status such as microemboli detection, dynamic autoregulation and long-duration real-time monitoring of flow characteristics. Although most of the information provided cannot be obtained by any other imaging methodology, and is critical in clinical decision-making in the care of various neurovascular diseases, these modalities are widely underutilized. Increasing the familiarity to neurosonological techniques is of crucial importance. AREAS COVERED IN THIS REVIEW After briefly reviewing TCD, TCDI and PMD techniques, classical features are summarized and recent developments in the clinical neurosonology applications with specific interest in the neurovascular disorders. WHAT THE READER WILL GAIN Practical perspectives of ultrasound evaluation of intracranial arterial status in various neurovascular diseases including sickle cell vasculopathy and vasospasm are reviewed in detail. Pearls on the neurosonological monitoring of acute ischemic stroke and increased intracranial pressure increase is provided. Standards of cerebral microembolism detection, right to left shunts diagnosis and cerebral autoregulation assessment are discussed methodologically. Future perspectives of therapeutic neurosonology including sonothrombolysis, microbubble-ultrasound-mediated gene and drug delivery into the brain, and alteration of the brain-blood barrier permeability are summarized. TAKE HOME MESSAGE Suitable with future medicine, neurosonology brings imaging to the bedside, which enables the treating physician to monitor a given intervention in real time. A non-invasive neurosonology-guided treatment of various diseases could be possible in the near future. The first and foremost step in gaining mastery in this very fruitful field is beginning to use it.
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Affiliation(s)
- Mehmet Akif Topcuoglu
- Hacettepe University Hospitals, Department of Neurology, Neurological Intensive Care Unit, 06100, Sihhiye, Ankara, Turkey +90 312 3051806 ; +90 312 3093451 ;
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Asymptomatic Carotid Stenosis: The Not-So-Silent Disease. J Am Coll Cardiol 2013; 61:2510-3. [DOI: 10.1016/j.jacc.2013.01.087] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 01/11/2013] [Accepted: 01/20/2013] [Indexed: 11/19/2022]
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Zanatta P, Forti A, Minniti G, Comin A, Mazzarolo AP, Chilufya M, Baldanzi F, Bosco E, Sorbara C, Polesel E. Brain emboli distribution and differentiation during cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2013; 27:865-75. [PMID: 23706643 DOI: 10.1053/j.jvca.2012.12.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Cardiopulmonary bypass (CPB) is a lifesaving practice in cardiac surgery, but its use frequently is associated with cerebral injury and neurocognitive dysfunctions. Despite the involvement of numerous factors, microembolism occurring during CPB seems to be one of the main mechanisms leading to such alterations. The aim of the present study was to characterize the occurrence of cerebral microembolism with reference to microembolic amount, nature, and distribution in different combinations of cardiac procedures and CPB on the microembolic load. DESIGN A retrospective observational clinical study. SETTING A single-center regional hospital. PARTICIPANTS Fifty-five patients undergoing elective cardiac surgery with CPB. INTERVENTIONS Bilateral detection of the patients' middle cerebral arteries using a multifrequency transcranial Doppler. MEASUREMENTS AND MAIN RESULTS Patients were divided into 3 groups depending on the CPB circuit used (open, open with vacuum, or closed). There was a significant difference between the number of solid and gaseous microemboli (p<0.001), with the solid lower than the gaseous ones. The number of solid microemboli was affected by group (p< 0.05), CPB phase (p<0.001), and laterality (p<0.01). The number of gaseous microemboli was affected only by group (p<0.05) and CPB phase (p<0.001). Generally, the length of CPB phase did not affect the number of microemboli. CONCLUSIONS Surgical procedures combined with CPB circuits, but not the CPB phase length, affected the occurrence, nature, and laterality of microemboli.
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Affiliation(s)
- Paolo Zanatta
- Department of Anesthesia and Intensive Care, Treviso Regional Hospital, Italy
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Almekhlafi MA, Demchuk AM, Mishra S, Bal S, Menon BK, Wiebe S, Clement FM, Wong JH, Hill MD, Goyal M. Malignant Emboli on Transcranial Doppler During Carotid Stenting Predict Postprocedure Diffusion-Weighted Imaging Lesions. Stroke 2013; 44:1317-22. [DOI: 10.1161/strokeaha.111.000659] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Mohammed A Almekhlafi
- Departments of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
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