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Piechocki M, Przewłocki T, Pieniążek P, Trystuła M, Podolec J, Kabłak-Ziembicka A. A Non-Coronary, Peripheral Arterial Atherosclerotic Disease (Carotid, Renal, Lower Limb) in Elderly Patients-A Review: Part I-Epidemiology, Risk Factors, and Atherosclerosis-Related Diversities in Elderly Patients. J Clin Med 2024; 13:1471. [PMID: 38592280 PMCID: PMC10935176 DOI: 10.3390/jcm13051471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 02/23/2024] [Accepted: 02/29/2024] [Indexed: 04/10/2024] Open
Abstract
Atherosclerosis is a generalized and progressive disease. Ageing is a key risk factor for atherosclerosis progression that is associated with the increased incidence of ischemic events in supplied organs, including stroke, coronary events, limb ischemia, or renal failure. Cardiovascular disease is the leading cause of death and major disability in adults ≥ 75 years of age. Atherosclerotic occlusive disease affects everyday activity and quality of life, and it is associated with reduced life expectancy. Although there is evidence on coronary artery disease management in the elderly, there is insufficient data on the management in older patients presented with atherosclerotic lesions outside the coronary territory. Despite this, trials and observational studies systematically exclude older patients, particularly those with severe comorbidities, physical or cognitive dysfunctions, frailty, or residence in a nursing home. This results in serious critical gaps in knowledge and a lack of guidance on the appropriate medical treatment and referral for endovascular or surgical interventions. Therefore, we attempted to gather data on the prevalence, risk factors, and management strategies in patients with extra-coronary atherosclerotic lesions.
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Affiliation(s)
- Marcin Piechocki
- Department of Vascular and Endovascular Surgery, The St. John Paul II Hospital, Prądnicka 80, 31-202 Krakow, Poland; (M.P.); (P.P.); (M.T.)
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Krakow, Poland;
| | - Tadeusz Przewłocki
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Krakow, Poland;
- Department of Interventional Cardiology, The St. John Paul II Hospital, Prądnicka 80, 31-202 Krakow, Poland;
| | - Piotr Pieniążek
- Department of Vascular and Endovascular Surgery, The St. John Paul II Hospital, Prądnicka 80, 31-202 Krakow, Poland; (M.P.); (P.P.); (M.T.)
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Krakow, Poland;
| | - Mariusz Trystuła
- Department of Vascular and Endovascular Surgery, The St. John Paul II Hospital, Prądnicka 80, 31-202 Krakow, Poland; (M.P.); (P.P.); (M.T.)
| | - Jakub Podolec
- Department of Interventional Cardiology, The St. John Paul II Hospital, Prądnicka 80, 31-202 Krakow, Poland;
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Krakow, Poland
| | - Anna Kabłak-Ziembicka
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Krakow, Poland
- Noninvasive Cardiovascular Laboratory, The St. John Paul II Hospital, Prądnicka 80, 31-202 Krakow, Poland
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Pathuri SC, Johnson WC, Webb MR, Fielder TC, Al-Saiegh F, Morton RP, Rodriguez P, Birnbaum L, Mascitelli JR. Development of the Circle of Willis Score (COWS) to help guide decision making during acute tandem occlusion treatment: Preliminary analysis. Clin Neurol Neurosurg 2024; 236:108116. [PMID: 38244414 DOI: 10.1016/j.clineuro.2024.108116] [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: 11/19/2023] [Revised: 01/03/2024] [Accepted: 01/05/2024] [Indexed: 01/22/2024]
Abstract
BACKGROUND Acute tandem occlusions (TOs) are challenging to treat. Although acute carotid stenting of the proximal lesion is well tolerated, there are certain situations when the practitioner may be wary of acute stenting (bleeding concerns). OBJECTIVE The purpose of this study was to retrospectively study patients with tandem occlusions who had re-occlusion of the extracranial ICA and develop a Circle of Willis Score (COWS) to help predict which patients could forego acute stenting. METHODS This is a retrospective review of TO patients with a persistent proximal occlusion following intervention (either expected or unexpected). Pre intervention CTA and intraoperative DSA were reviewed, and each patient was assigned a score 2 (complete COW), 1a (patent A1-Acomm-A1), 1p (patent Pcomm), or 0 (incomplete COW). Findings from the DSA took precedence over the CTA. Two cohorts were created, the complete COW cohort (COWS 2) versus the incomplete COW cohort (COWS 1a,1p, or 0). Angiographic outcomes were assessed using the mTICI score (2b-3) and clinical outcomes were assessed using discharge mRS (good outcome mRS 0-3). RESULTS Of 68 TO cases, 12 had persistent proximal occlusions. There were 5/12 (42 %) patients in the complete COW cohort, and 7/12 (58 %) in the incomplete COW cohort (5/12 with scores of 1a/1p and 2/12 with a score of 0). In the complete COW cohort, there were 2 ICA-ICA and 3 ICA-MCA occlusions. In the incomplete COW cohort, there was one ICA-ICA occlusion and 6 ICA-MCA occlusions. LKW-puncture was shorter in the complete COW cohort (208 min vs. 464 min, p = 0.16). Successful reperfusion was higher in the complete COW cohort (100 % vs. 71 %). There was a trend toward better clinical outcomes in the complete COW cohort (80 % vs 29 %, p = 0.079). CONCLUSION The COWS is a simple score that may help predict a successful clinical outcome without proximal revascularization when concerned about performing an acute carotid stent during TO treatment. Evaluation in larger TO cohort is warranted.
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Affiliation(s)
- Sarath C Pathuri
- Department of Neurosurgery, University of Texas Health Sciences Center San Antonio, San Antonio, TX, USA.
| | - William C Johnson
- Department of Neurosurgery, University of Texas Health Sciences Center San Antonio, San Antonio, TX, USA.
| | - Matthew R Webb
- Department of Neurosurgery, University of Texas Health Sciences Center San Antonio, San Antonio, TX, USA.
| | - Tristan C Fielder
- Department of Neurosurgery, University of Texas Health Sciences Center San Antonio, San Antonio, TX, USA.
| | - Fadi Al-Saiegh
- Department of Neurosurgery, University of Texas Health Sciences Center San Antonio, San Antonio, TX, USA.
| | - Ryan P Morton
- Department of Neurosurgery, University of Texas Health Sciences Center San Antonio, San Antonio, TX, USA; Department of Neurosurgery, Brooke Army Medical Center, San Antonio, TX, USA.
| | - Pavel Rodriguez
- Department of Neurosurgery, University of Texas Health Sciences Center San Antonio, San Antonio, TX, USA.
| | - Lee Birnbaum
- Department of Neurosurgery, University of Texas Health Sciences Center San Antonio, San Antonio, TX, USA.
| | - Justin R Mascitelli
- Department of Neurosurgery, University of Texas Health Sciences Center San Antonio, San Antonio, TX, USA.
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Wawak M, Tekieli Ł, Badacz R, Pieniążek P, Maciejewski D, Trystuła M, Przewłocki T, Kabłak-Ziembicka A. Clinical Characteristics and Outcomes of Aortic Arch Emergencies: Takayasu Disease, Fibromuscular Dysplasia, and Aortic Arch Pathologies: A Retrospective Study and Review of the Literature. Biomedicines 2023; 11:2207. [PMID: 37626704 PMCID: PMC10452526 DOI: 10.3390/biomedicines11082207] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/02/2023] [Accepted: 08/04/2023] [Indexed: 08/27/2023] Open
Abstract
Non-atherosclerotic aortic arch pathologies (NA-AAPs) and anatomical variants are characterized as rare cardiovascular diseases with a low incidence rate, below 1 case per 2000 population, but enormous heterogeneity in terms of anatomical variants, i.e., Takayasu disease (TAK) and fibromuscular dysplasia (FMD). In specific clinical scenarios, NA-AAPs constitute life-threatening disorders. METHODS In this study, 82 (1.07%) consecutive patients with NA-AAPs (including 38 TAKs, 26 FMDs, and 18 other AAPs) out of 7645 patients who underwent endovascular treatment (EVT) for the aortic arch and its side-branch diseases at a single institution between 2002 and 2022 were retrospectively reviewed. The recorded demographic, biochemical, diagnostic, operative, and postoperative factors were reviewed, and the functional outcomes were determined during follow-up. A systematic review of the literature was also performed. RESULTS The study group comprised 65 (79.3%) female and 17 (21.7%) male subjects with a mean age of 46.1 ± 14.9 years. Overall, 62 (75.6%) patients were diagnosed with either cerebral ischemia symptoms or aortic arch dissection on admission. The EVT was feasible in 59 (72%) patients, whereas 23 (28%) patients were referred for medical treatment. In EVT patients, severe periprocedural complications occurred in two (3.39%) patients, including one periprocedural death and one cerebral hyperperfusion syndrome. During a median follow-up period of 64 months, cardiovascular events occurred in 24 (29.6%) patients (5 deaths, 13 ISs, and 6 myocardial infarctions). Repeated EVT for the index lesion was performed in 21/59 (35.6%) patients, including 19/33 (57.6%) in TAK and 2/13 (15.4%) in FMD. In the AAP group, one patient required additional stent-graft implantation for progressing dissection to the iliac arteries at 12 months. A baseline white blood count (odds ratio [HR]: 1.25, 95% confidence interval [CI]: 1.11-1.39; p < 0.001) was the only independent prognostic factor for recurrent stenosis, while a baseline hemoglobin level (HR: 0.73, 95%CI: 0.59-0.89; p = 0.002) and coronary involvement (HR: 4.11, 95%CI: 1.74-9.71; p = 0.001) were independently associated with a risk of major cardiac and cerebral events according to the multivariate Cox proportional hazards regression analysis. CONCLUSIONS This study showed that AAPs should not be neglected in clinical settings, as it can be a life-threatening condition requiring a multidisciplinary approach. The knowledge of prognostic risk factors for adverse outcomes may improve surveillance in this group of patients.
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Affiliation(s)
- Magdalena Wawak
- Department of Interventional Cardiology, The John Paul II Hospital, Prądnicka 80, 31-202 Kraków, Poland
| | - Łukasz Tekieli
- Department of Interventional Cardiology, The John Paul II Hospital, Prądnicka 80, 31-202 Kraków, Poland
| | - Rafał Badacz
- Department of Interventional Cardiology, The John Paul II Hospital, Prądnicka 80, 31-202 Kraków, Poland
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Kraków, Poland
| | - Piotr Pieniążek
- Department of Interventional Cardiology, The John Paul II Hospital, Prądnicka 80, 31-202 Kraków, Poland
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Kraków, Poland
| | - Damian Maciejewski
- Department of Interventional Cardiology, The John Paul II Hospital, Prądnicka 80, 31-202 Kraków, Poland
| | - Mariusz Trystuła
- Department of Vascular and Endovascular Surgery, The John Paul II Hospital, Prądnicka 80, 31-202 Kraków, Poland;
| | - Tadeusz Przewłocki
- Department of Interventional Cardiology, The John Paul II Hospital, Prądnicka 80, 31-202 Kraków, Poland
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Kraków, Poland
| | - Anna Kabłak-Ziembicka
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, św. Anny 12, 31-007 Kraków, Poland
- Noninvasive Cardiovascular Laboratory, The John Paul II Hospital, Prądnicka 80, 31-202 Kraków, Poland
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Zarrinkoob L, Wåhlin A, Ambarki K, Eklund A, Malm J. Quantification and mapping of cerebral hemodynamics before and after carotid endarterectomy, using four-dimensional flow magnetic resonance imaging. J Vasc Surg 2021; 74:910-920.e1. [PMID: 33812036 DOI: 10.1016/j.jvs.2021.01.074] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 01/26/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Carotid stenosis can profoundly affect cerebral hemodynamics, which cannot simply be inferred from the degree of stenosis. We quantified and mapped the distribution of the blood flow rate (BFR) in the cerebral arteries before and after carotid endarterectomy using four-dimensional (4D) phase-contrast (PC) magnetic resonance imaging (MRI). METHODS Nineteen patients (age, 71 ± 6 years; 2 women) with symptomatic carotid stenosis (≥50%) undergoing carotid endarterectomy (CEA) were investigated using 4D PC-MRI before and after surgery. The BFR was measured in 17 cerebral arteries and the ophthalmic arteries. Collateral recruitment through the anterior and posterior communicating arteries, ophthalmic arteries, and leptomeningeal arteries was quantified. BFR laterality was significantly different between the paired contralateral and ipsilateral arteries. Subgroups were defined according to the presence of collateral recruitment. RESULTS The total cerebral blood flow had increased by 15% (P < .01) after CEA. Before CEA, laterality was seen in the internal carotid artery, anterior cerebral artery, and middle cerebral artery (MCA). On the ipsilateral side, an increased BFR was found after CEA in the internal carotid artery (246 ± 62 mL/min vs 135 ± 80 mL/min; P < .001), anterior cerebral artery (87 ± mL/min vs 38 ± 58 mL/min; P < .01), and MCA (149 ± 43 mL/min vs 119 ± 34 mL/min; P < .01), resulting in a postoperative BFR distribution without signs of laterality. In the nine patients with preoperatively recruited collaterals, BFR laterality was found in the MCA before, but not after, CEA (P < .01). This laterality was not found in the 10 patients without collateral recruitment (P = .2). The degree of stenosis did not differ between the groups with and without collateral recruitment (P = .85). CONCLUSIONS Using 4D PC-MRI, we have presented a comprehensive and noninvasive method to evaluate the cerebral hemodynamics due to carotid stenosis before and after CEA. MCA laterality, seen in the patients with collateral recruitment before CEA, pointed toward a hemodynamic disturbance in MCA territory for those patients. This methodologic advancement provides an insight into the pathophysiology of cerebral hemodynamics in patients with carotid stenosis.
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Affiliation(s)
- Laleh Zarrinkoob
- Division of Neuroscience, Department of Clinical Sciences, Umeå University, Umeå, Sweden; Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden.
| | - Anders Wåhlin
- Department of Radiation Sciences, Umeå University, Umeå, Sweden; Centre for Biomedical Engineering and Physics, Umeå University, Umeå, Sweden; Umeå Center for Functional Brain Imaging, Umeå University, Umeå, Sweden
| | - Khalid Ambarki
- Department of Radiation Sciences, Umeå University, Umeå, Sweden; Centre for Biomedical Engineering and Physics, Umeå University, Umeå, Sweden
| | - Anders Eklund
- Department of Radiation Sciences, Umeå University, Umeå, Sweden; Centre for Biomedical Engineering and Physics, Umeå University, Umeå, Sweden
| | - Jan Malm
- Division of Neuroscience, Department of Clinical Sciences, Umeå University, Umeå, Sweden
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Akkaya E, Nazliel B, Caglayan Batur H, Ilgit E, Onal B, Akkan K, Irkec C. Pre- and Post-stenting Cerebral Blood Flow Velocities in Patients with Carotid Artery Stenosis. Neurol India 2021; 69:1711-1715. [DOI: 10.4103/0028-3886.333439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Wang P, Wang Y, Zhang Q. Intracranial hemorrhage after carotid artery stenting in both anterior and posterior circulation: A case report. Medicine (Baltimore) 2018; 97:e13800. [PMID: 30572539 PMCID: PMC6319777 DOI: 10.1097/md.0000000000013800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONAL Intracranial hemorrhage (ICH) after carotid artery stenting (CAS) is a rare but fatal complication, and it primarily occurs in the corresponding vascular distribution area. Herein, a case of ICH after CAS in both anterior and posterior circulation has been described. PATIENT CONCERNS A 62-year-old female was referred to the hospital for left-side limb weakness and right nasal hemianopia for 1 month. DIAGNOSIS Cerebral MRI following hospitalization revealed cerebral infarction in the right posterior cortical watershed area. Computed tomography angiography (CTA) showed severe stenosis in the right internal carotid artery. INTERVENTIONS We performed CAS to treat the right internal carotid artery stenosis without any complications. OUTCOMES After CAS, cerebral hemorrhage occurred under strict control of blood pressure in both anterior and posterior circulation. After 69 days of treatment, the patient was discharged from the hospital. LESSONS Hypertension is still one of the causes of ICH after CAS. The control of perioperative BP in patients with severe carotid stenosis is yet a major concern.
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Abreu P, Nogueira J, Rodrigues FB, Nascimento A, Carvalho M, Marreiros A, Nzwalo H. Intracerebral hemorrhage as a manifestation of cerebral hyperperfusion syndrome after carotid revascularization: systematic review and meta-analysis. Acta Neurochir (Wien) 2017; 159:2089-2097. [PMID: 28916863 DOI: 10.1007/s00701-017-3328-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 09/05/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) in the context of cerebral hyperperfusion syndrome (CHS) is an uncommon but potentially lethal complication after carotid revascularization for carotid occlusive disease. Information about its incidence, risk factors and fatality is scarce. Therefore, we aimed to perform a systematic review and meta-analysis focusing on the incidence, risk factors and outcomes of ICH in the context of CHS after carotid revascularization. METHODS We searched the PubMed and EBSCO hosts for all studies published in English about CHS in the context of carotid revascularization. Two reviewers independently assessed each study for eligibility based on predefined criteria. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and the PROSPERO register was made (register no. CRD42016033190), including the pre-specified protocol. RESULTS Forty-one studies involving 28,956 participants were deemed eligible and included in our analysis. The overall quality of the included studies was fair. The pooled frequency of ICH in the context of CHS was 38% (95% CI: 26% to 51%, I2 = 84%, 24 studies), and the pooled case fatality of ICH after CHS was 51% (95% CI: 32% to 71%, I2 = 77%, 17 studies). When comparing carotid angioplasty with stenting (CAS) with carotid endarterectomy (CEA), post-procedural ICH in the context of CHS was less frequent in CEA. ICH following CHS occurred less often in large series and was rare in asymptomatic patients. The most common risk factors were periprocedural hypertension and ipsilateral severe stenosis. CONCLUSIONS ICH as a manifestation of CHS is rare, more frequent after CAS and associated with poor prognosis. Periprocedural control of hypertension can reduce its occurrence.
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Affiliation(s)
- Pedro Abreu
- Department of Biomedical Sciences and Medicine, University of Algarve, Campus da Penha, 8005-139, Faro, Portugal
| | - Jerina Nogueira
- Department of Biomedical Sciences and Medicine, University of Algarve, Campus da Penha, 8005-139, Faro, Portugal
| | - Filipe Brogueira Rodrigues
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal
- Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
- Huntington's Disease Centre, Institute of Neurology, University College London, London, UK
| | - Ana Nascimento
- Department of Neurology, Centro Hospitalar do Algarve, Faro, Portugal
| | - Mariana Carvalho
- Department of Neurology, Centro Hospitalar do Algarve, Faro, Portugal
| | - Ana Marreiros
- Department of Biomedical Sciences and Medicine, University of Algarve, Campus da Penha, 8005-139, Faro, Portugal
| | - Hipólito Nzwalo
- Department of Biomedical Sciences and Medicine, University of Algarve, Campus da Penha, 8005-139, Faro, Portugal.
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Magnetic resonance imaging and clinical outcome in patients with symptomatic carotid artery stenosis after carotid artery revascularization. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2017; 13:225-232. [PMID: 29056995 PMCID: PMC5644041 DOI: 10.5114/aic.2017.70190] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 06/12/2017] [Indexed: 11/25/2022] Open
Abstract
Introduction About 30% of patients with carotid artery stenosis (CAS) develop dementia after a cerebral ischemic event (CIE), and 20–50% suffer from CIE recurrence during 6 months. Carotid artery revascularization (CAR) may prevent CIE recurrence, at the cost of new microembolic lesions (MES). The impact of CAR on cognitive function is debatable. Aim To assess functional and cognitive outcome, cerebral flow on transcranial Doppler (TCD) and brain magnetic resonance imaging (MRI) in patients with symptomatic CAS referred for CAR. Material and methods Twenty-two patients (aged 69.0 ±7.2 y.o., 15 male) with recent CIE (21.9 ±20.9 days to CAR) related to CAS of mean 89.8 ±3.9% lumen reduction were prospectively evaluated with TCD, diffusion and perfusion MRI, Montreal Cognitive Assessment (MoCA), Mini Mental State Examination (MMSE), modified Rankin Scale (mRS) and the National Institutes of Health Stroke Scale (NIHSS) 24 h before, at 24–48 h and 1 month following CAR. Results New MES were found in 11 (50%) subjects following CAR. CAR resulted in a significant increase of cerebral flow velocity in the middle and anterior cerebral arteries (p < 0.002 and p = 0.003; respectively) and cerebral perfusion measured by time to peak (TTP) and mean transit time (MTT) (p = 0.0009 and p = 0.0002; respectively). Neurologic tests showed improvement in NIHSS (2.4 ±1.6 to 1.5 ±1.2, p = 0.003), mRS (from 1.3 ±0.9 to 0.7 ±0.9, p = 0.005), and MMSE (26.7 ±2.2 to 27.6 ±2.3, p = 0.019) at 1 month, while similar MoCA scores were observed before and 1 month after CAR (23.4 ±3.3 vs. 24.1 ±3.7, p = 0.136). Conclusions Improvement of cerebral flow and perfusion and functional outcome, as well as at least no cognitive decline, is observed after CAR for symptomatic CAS.
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Telman G, Kouperberg E, Sprecher E, Gruberg L, Beyar R, Yarnitsky D. TCD Evaluation before and after Stenting in Patients with Severe Primary Carotid Artery Stenosis versus Restenosis. J Endovasc Ther 2016; 14:483-8. [PMID: 17696622 DOI: 10.1177/152660280701400408] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To evaluate cerebral hemodynamics before and after carotid angioplasty and stenting (CAS) using transcranial Doppler (TCD). Methods: Sixty-eight patients (52 men; mean age 69±9.5 years) with severe carotid stenosis (83.4%±10.2%) were examined by TCD before and 2 months after CAS. Thirty-two (47%) patients had primary carotid stenosis and 36 (53%) had restenosis after carotid endarterectomy (CEA). A broad TCD protocol was employed to estimate cerebral hemodynamics, including assessment of velocities (V) and asymmetry of cerebral blood flow velocity (CBFV) in the middle cerebral artery, (MCA) anterior cerebral artery (ACA), and basilar artery (BA); the pulsatility indexes; and flow acceleration. Results: Ipsilateral MCA mean velocities before stenting were 46.3±12.6 cm/s in the primary stenosis group and 47.1±12.3 cm/s in restenosis group; after stenting, the velocities were 53.8±12.1 and 52.7±9.6 cm/s, respectively (p<0.005 for both groups). MCA asymmetry by Vmean before CAS was higher in the primary stenosis group (27.6%±2.4% versus 19.8%±2.3%, p<0.05). After stenting, this index was significantly lower in both groups: 16.4%±2.4% and 12.3%±2.3%, respectively (p<0.0001 for each group). All other TCD parameters improved significantly in both groups after CAS as well (p<0.05), showing the strong hemodynamic effect of this procedure. Conclusion: CAS effectively improves cerebral hemodynamics in patients with severe primary and restenosis of the internal carotid artery.
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Affiliation(s)
- Gregory Telman
- Department of Neurology, Rambam Health Care Campus, Haifa, Israel.
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Bost RB, Hendrikse J, Algra A, de Borst GJ, Kappelle LJ, Jongen LM, Brown MM, van der Worp HB. Effects of Carotid Endarterectomy or Stenting on Arterial Diameters in the Circle of Willis. J Stroke Cerebrovasc Dis 2014; 23:699-705. [DOI: 10.1016/j.jstrokecerebrovasdis.2013.06.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2013] [Revised: 05/16/2013] [Accepted: 06/10/2013] [Indexed: 10/26/2022] Open
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Buczek J, Karliński M, Kobayashi A, Białek P, Członkowska A. Hyperperfusion syndrome after carotid endarterectomy and carotid stenting. Cerebrovasc Dis 2013; 35:531-7. [PMID: 23817298 DOI: 10.1159/000350736] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 03/07/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hyperperfusion syndrome (HS) is a relatively rare but possibly serious complication of carotid revascularization procedures. Impaired cerebral autoregulation and postrevascularization changes in cerebral blood flow are the main mechanisms involved in the development of HS. Most up-to-date studies addressing this issue are retrospective and tend to concentrate on carotid endarterectomy (CEA), neglecting carotid stenting (CAS). Our aim was to compare the frequency of clinical signs of HS and hyperperfusion detected by transcranial Doppler (TCD) in patients undergoing CAS or CEA due to carotid stenosis. METHODS In this prospective observational study, we evaluated 61 patients scheduled for routine CAS or CEA. Each patient was examined by a neurologist before and after the revascularization procedure to assess the clinical status. Severe headache, ocular or facial pain, confusion, visual disturbances, epileptic seizures or any focal deficits not caused by cerebral ischemia were considered clinical signs of HS. Peak systolic velocity (PSV), end-diastolic velocity, mean velocity (MV), and pulsatility index were measured by TCD once before and twice after the intervention (within 6 h after and 2-5 days after the procedure). Hyperperfusion was defined as a >100% increase in the middle cerebral artery (MCA) blood velocity, evaluated separately for PSV and MV after the procedure compared with the baseline value. Cerebrovascular reactivity (CVR) was evaluated with a TCD acetazolamide test before the intervention. RESULTS CAS (n = 33) and CEA (n = 28) patients were included in the study. There was no difference between the groups in the frequency of clinical signs of HS (21.2 vs. 21.4%) and ratio of TCD hyperperfusion (12.1 vs. 14.3%). In the CAS group, ipsilateral MCA velocity significantly increased directly after the intervention and 2-5 days later, while it increased in the CEA group only 2-5 days after the intervention. The sensitivity and specificity of hyperperfusion, defined by MV, for HS signs were 38.5 and 93.8%, respectively, whereas those defined by PSV were 30.8 and 89.6%, respectively. The sensitivity and specificity of impaired CVR (<25%) for HS signs were 63.6 and 73.5%, respectively. CONCLUSIONS There is no difference in the frequency of HS clinical signs and hyperperfusion detected by TCD between patients after CAE and CAS. Clinical signs suggested HS does not always correspond with TCD hyperperfusion. However, both the CVR test and TCD measurements of MCA velocity can help identify patients at high risk for HS.
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Affiliation(s)
- Julia Buczek
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland.
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Takami H, Hanakawa K, Sato H, Tsutsumi K, Murao M, Ide T. Contralateral hyperacute intracerebral hemorrhage after carotid artery stenting with contralateral internal carotid artery occlusion. J Vasc Surg 2013; 59:821-4. [PMID: 23769942 DOI: 10.1016/j.jvs.2013.04.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 02/11/2013] [Accepted: 04/20/2013] [Indexed: 10/26/2022]
Abstract
An 87-year-old man sustained an intracerebral hemorrhage in the watershed area of the contralateral frontal lobe immediately after carotid artery stenting (CAS) for severe cervical internal carotid artery (ICA) stenosis. The contralateral cervical ICA was occluded. CAS resulted in increased cross-flow through the anterior communicating artery and increased flow in the contralateral middle cerebral artery. This case demonstrates that CAS in patients with contralateral ICA occlusion and insufficient collateral flow can cause dramatically increased collateral flow through the circle of Willis and result in contralateral hyperperfusion. In patients with severely compromised cerebral perfusion, measures should be taken to prevent hyperperfusion-related complications.
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Affiliation(s)
- Hirokazu Takami
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan.
| | - Kazuo Hanakawa
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Hiroaki Sato
- Department of Neuroendovascular Therapy, Tokyo Metropolitan Police Hospital, Tokyo, Japan
| | - Kyouske Tsutsumi
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Masahiko Murao
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Takafumi Ide
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
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Hsu LC, Chang FC, Kuo TBJ, Wong WJ, Hu HH. Cerebral hemodynamics and baroreflex sensitivity after carotid artery stenting. Acta Neurol Scand 2013; 127:46-52. [PMID: 22616889 DOI: 10.1111/j.1600-0404.2012.01679.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2012] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The long-term hemodynamic effects of carotid angioplasty and stenting (CAS) are unclear. We performed a longitudinal study to investigate the variations in cerebral hemodynamics in patients undergoing CAS. MATERIALS AND METHODS We performed prospective evaluation of 63 symptomatic male patients (19 patients had transient ischemic attack and 44 had minor stroke; mean age: 77.3 ± 6.3 years [range: 51-86]). The mean blood flow velocities (MBFV) and pulsatility index (PI) of the middle cerebral arteries (MCA) on both sides were evaluated using transcranial color-coded Doppler (TCCD) ultrasonography. Cardiac autonomic activities were evaluated by measuring baroreflex sensitivity (BRS). All parameters were measured at baseline prior to CAS and at 1, 3, 6, and 12 months after CAS. RESULTS The preoperative MBFV and PI of the ipsilateral MCA were significantly lower than those of the contralateral side. However, after CAS, MBFV in the ipsilateral MCA increased significantly until 2 weeks after stenting, after which the MBFV gradually decreased and remained stable for 1 year after CAS. Further, we observed a nonsignificant increase in MBFV in the contralateral MCA after CAS. In contrast to the MBFV, the BRS values decreased significantly 1 month after stenting and returned to baseline levels 6 months after CAS. CONCLUSIONS Patients with CAS showed improved global cerebral hemodynamic status. However, the BRS did not normalize initially, and baseline value was achieved at 6 months after stenting.
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Affiliation(s)
| | | | - T. B. J. Kuo
- Institute of Brain Science, National Yang-Ming University; Taipei; Taiwan
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Chuang YM, Huang KL, Chang YJ, Chang CH, Chang TY, Wu TC, Wong HF, Liu SJ, Lee TH. Immediate Regression of Leukoaraiosis after Carotid Artery Revascularization. Cerebrovasc Dis 2011; 32:439-46. [DOI: 10.1159/000330638] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Accepted: 06/14/2011] [Indexed: 11/19/2022] Open
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Kablak-Ziembicka A, Przewlocki T, Pieniazek P, Musialek P, Tekieli L, Rosławiecka A, Motyl R, Zmudka K, Tracz W, Podolec P. Predictors of cerebral reperfusion injury after carotid stenting: the role of transcranial color-coded Doppler ultrasonography. J Endovasc Ther 2010; 17:556-63. [PMID: 20681776 DOI: 10.1583/09-2980.1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE To evaluate the possible role of transcranial color-coded Doppler ultrasonography (TCD) in predicting cerebral reperfusion injury (CRI) in patients undergoing carotid artery stenting (CAS) for internal carotid artery (ICA) stenosis. METHODS TCD was obtained in 210 patients (149 men; mean age 64.2+/-8.4 years, range 44-83) who underwent CAS for ICA stenosis averaging 86.7%+/-8.4%. Contralateral ICA occlusion or near occlusion (stenosis >90%) was present in 67 (31.9%) patients. TCD was performed before and 24 hours after CAS with assessment of peak systolic velocities (PSVs) in the ipsilateral middle cerebral artery (iMCA) and contralateral middle cerebral artery (cMCA). PSV ratios (PSVR) in the iMCA and cMCA were calculated from the PSVs before and after CAS. RESULTS CRI syndrome occurred in 3 (1.4%) patients (2 intracranial bleedings, 1 subarachnoid hemorrhage). The mean iMCA and cMCA PSVRs were 2.66+/-0.19 and 4.16+/-2.77, respectively, in CRI patients, while the PSVRs in CAS patients without neurological sequelae were 1.56+/-0.46 and 1.21+/-0.39, respectively (both p<0.001). The combination of iPSVR>2.4 and cPSVR>2.4 occurred in 4 patients with bilateral ICA disease; 3 (75%) of them developed CRI (100% sensitivity and 99% specificity for CRI prediction). The following independent CRI predictors were identified: combined iPSVR>2.4 and cPSVR>2.4 (RR 2.06, CI 1.89 to 2.24; p<0.001), high cMCA PSV after CAS (RR 1.23, CI 1.13 to 1.34; p<0.001), and contralateral ICA occlusion (RR 1.13, CI 1.03 to 1.23; p = 0.007). CONCLUSION TCD is an important tool in CRI risk evaluation. The combination of iPSVR>2.4 and cPSVR>2.4 is an independent CRI risk factor, along with contralateral ICA occlusion and high cMCA PSVs after CAS.
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Affiliation(s)
- Anna Kablak-Ziembicka
- Departments of Cardiac and Vascular Diseases and, The John Paul II Hospital, Krakow, Poland.
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Bokkers R, van Laar P, van der Zwan A, Mali W, Hendrikse J. Mixed perfusion: A combined blood supply to the brain tissue by multiple arteries. J Neuroradiol 2010; 37:201-10. [DOI: 10.1016/j.neurad.2010.01.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2009] [Revised: 01/27/2010] [Accepted: 01/28/2010] [Indexed: 11/27/2022]
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Beach KW, Bergelin RO, Leotta DF, Primozich JF, Sevareid PM, Stutzman ET, Zierler RE. Standardized ultrasound evaluation of carotid stenosis for clinical trials: University of Washington Ultrasound Reading Center. Cardiovasc Ultrasound 2010; 8:39. [PMID: 20822530 PMCID: PMC2944149 DOI: 10.1186/1476-7120-8-39] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Accepted: 09/07/2010] [Indexed: 11/10/2022] Open
Abstract
Introduction Serial monitoring of patients participating in clinical trials of carotid artery therapy requires noninvasive precision methods that are inexpensive, safe and widely available. Noninvasive ultrasonic duplex Doppler velocimetry provides a precision method that can be used for recruitment qualification, pre-treatment classification and post treatment surveillance for remodeling and restenosis. The University of Washington Ultrasound Reading Center (UWURC) provides a uniform examination protocol and interpretation of duplex Doppler velocity measurements. Methods Doppler waveforms from 6 locations along the common carotid and internal carotid artery path to the brain plus the external carotid and vertebral arteries on each side using a Doppler examination angle of 60 degrees are evaluated. The UWURC verifies all measurements against the images and waveforms for the database, which includes pre-procedure, post-procedure and annual follow-up examinations. Doppler angle alignment errors greater than 3 degrees and Doppler velocity measurement errors greater than 0.05 m/s are corrected. Results Angle adjusted Doppler velocity measurements produce higher values when higher Doppler examination angles are used. The definition of peak systolic velocity varies between examiners when spectral broadening due to turbulence is present. Examples of measurements are shown. Discussion Although ultrasonic duplex Doppler methods are widely used in carotid artery diagnosis, there is disagreement about how the examinations should be performed and how the results should be validated. In clinical trails, a centralized reading center can unify the methods. Because the goals of research examinations are different from those of clinical examinations, screening and diagnostic clinical examinations may require fewer velocity measurements.
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Affiliation(s)
- Kirk W Beach
- D, Eugene Strandness Vascular Laboratory, Department of Surgery, University of Washington, Seattle, Washington 98195, USA.
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Moulakakis KG, Mylonas SN, Sfyroeras GS, Andrikopoulos V. Hyperperfusion syndrome after carotid revascularization. J Vasc Surg 2009; 49:1060-8. [PMID: 19249185 DOI: 10.1016/j.jvs.2008.11.026] [Citation(s) in RCA: 139] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2008] [Revised: 11/06/2008] [Accepted: 11/06/2008] [Indexed: 10/21/2022]
Abstract
Cerebral hyperperfusion syndrome is a rare, serious complication of carotid revascularization either after carotid endarterectomy or carotid stent placement. Impaired cerebral autoregulation and post-revascularization changes in cerebral hemodynamics are the main mechanisms involved in the development of the syndrome. Hyperperfusion syndrome may be fatal once an intracranial hemorrhage occurs. This article reviews the literature, intending to make a synthesis of all new data concerning the clinical manifestations of hyperperfusion syndrome, the pathophysiologic pathways involved in its development, the prediction, and the appropriate management. Also, a review of the most recent series of hyperperfusion syndrome following carotid revascularization, both with classic open endarterectomy and carotid artery stenting has been performed.
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Telman G, Kouperberg E, Sprecher E, Gruberg L, Beyar R, Yarnitsky D. TCD Evaluation Before and After Stenting in Patients With Severe Primary Carotid Artery Stenosis Versus Restenosis. J Endovasc Ther 2007. [DOI: 10.1583/1545-1550(2007)14[483:tebaas]2.0.co;2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Subarachnoid hemorrhage after carotid artery stenting. J Vasc Surg 2007; 45:1072-5. [PMID: 17466804 DOI: 10.1016/j.jvs.2007.01.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2006] [Accepted: 01/09/2007] [Indexed: 11/22/2022]
Abstract
We describe subarachnoid hemorrhage (SAH) in a 66-year-old man, who underwent technically successful carotid stenting for a string-stenosis of the right internal carotid artery (ICA) in a presence of contralateral ICA occlusion with recurrent right hemisphere transient ischemic attacks. At 2 hours, the patient developed headache and vomiting, but no focal neurological deficits. Performed transcranial color-coded Doppler (TCCD) showed over 2.8-fold increase of the peak systolic velocity in the right middle cerebral artery. The emergent CT of the brain showed SAH with the right hemisphere edema. Patient was treated with Nimodipine in continuous infusion, diuretics i.v. and additional hypotensive therapy depending on blood pressure values. Clopidogrel was stopped for 5 days. Over next 4 weeks, a gradual cerebral velocities decrease was observed on TCCD, which was related to clinical and CT resolution.
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Affiliation(s)
- David M Pelz
- The University of Western Ontario, London, Ontario, Canada.
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