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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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Delgardo M, Rabin G, Tudor T, Tang AJ, Reeves G, Connolly ES. Monitoring risk and preventing ischemic stroke in the very old. Expert Rev Neurother 2023; 23:791-801. [PMID: 37540092 DOI: 10.1080/14737175.2023.2244674] [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: 04/29/2023] [Revised: 07/28/2023] [Accepted: 08/01/2023] [Indexed: 08/05/2023]
Abstract
INTRODUCTION Stroke is a significant cause of death, and the leading cause of severe long-term disability for individuals over 80 (the very old), yet few studies of such risk factors for ischemic stroke, or the known mitigation techniques, in this population, and the evidence base regarding risk modification strategies in this susceptible population can be inconsistent and incomplete. This article examines current guidelines and evidence regarding medical management, lifestyle changes, and psychosocial interactions that can contribute to the primary and secondary prevention of ischemic stroke in the very old. AREAS COVERED The authors conducted a literature search for ischemic stroke prevention and risk assessment in the elderly via PubMed. Furthermore, they describe current strategies for monitoring risk and preventing ischemic stroke in the elderly population. EXPERT OPINION Ischemic stroke poses a significant health risk to the elderly, with prevention relying on managing modifiable risk factors such as hypertension, atrial fibrillation, diabetes, and high cholesterol, as well as promoting healthy lifestyle choices like quitting smoking, regular physical activity and a heart-healthy diet. Healthcare providers must adopt a multifaceted approach, addressing individual and population-level factors while remaining vigilant in monitoring and managing risk factors to reduce the incidence and impact of stroke in older adults.
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Affiliation(s)
- Mychael Delgardo
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Grant Rabin
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Thilan Tudor
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Anthony J Tang
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Geoffrey Reeves
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - E Sander Connolly
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
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Feng Y, Bai X, Zhang X, Wang T, Lu X, Yang K, Ling F, Ma Y, Jiao L. Risk factors for new ischemic cerebral lesions after carotid artery stenting: A systematic review and meta-analysis. Ann Vasc Surg 2021; 77:296-305. [PMID: 34437972 DOI: 10.1016/j.avsg.2021.05.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 04/13/2021] [Accepted: 05/11/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND New ischemic cerebral lesions (NICL) are commonly occur after carotid artery stenting (CAS) with an incidence rate ranging from 18-58% and are detected by diffusion-weighted imaging-magnetic resonance imaging (DWI-MRI). Numerous studies have reported that NICL could increase the risk of future cerebrovascular events and cognitive impairment. This systematic review and meta-analysis aimed to identify risk factors for NICL after CAS. METHODS Relevant literature reporting risk factors for NICL after CAS were searched. Randomized controlled trials, case-control studies, or cohort studies were included in accordance with the pre-specified eligibility criteria. The risk of bias was assessed using the Cochrane Collaboration criteria and the quality of evidence was assessed with the corresponding scale. Data were analyzed using the RevMan V. 5.3 analysis software. RESULTS The final analyses included a total of 21 studies and 1907 participants, including 764 NICL-positives and 1143 NICL-negatives. Determinants for NICL-positivity were age (mean deviation (MD): 2.60; 95% confidence interval (CI): [1.53-3.68]), symptomatic carotid lesions (odds ratio (OR): 1.77; 95% CI: [1.39-2.25]) and smoking (OR: 0.74; 95% CI: [0.58-0.94]). For symptomatic patients, risk factors for NICL-positive included diabetes mellitus (OR: 1.76; 95% CI: [1.09-2.82]), but smoking (OR: 0.54; 95% CI: [0.31-0.93]) was a protective factor. Risk factors for centers with high NICL incidence were age (MD: 2.05; 95% CI: [0.93-3.17]) and symptomatic carotid lesions (OR: 1.77; 95% CI: [1.29-2.45]). CONCLUSIONS Older age and symptomatic carotid lesions are associated with an increased risk of post-CAS NICL whereas smoking is associated with a decreased risk. Risk factors for NICL in symptomatic patients is diabetes mellitus, while those for patients at centers with high incidence are age and symptomatic carotid lesions. Systematic review registration: CRD42019121129.
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Affiliation(s)
- Yao Feng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; China International Neuroscience Institute (China-INI), Beijing, China
| | - Xuesong Bai
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; China International Neuroscience Institute (China-INI), Beijing, China
| | - Xiao Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; China International Neuroscience Institute (China-INI), Beijing, China
| | - Tao Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; China International Neuroscience Institute (China-INI), Beijing, China
| | - Xia Lu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; China International Neuroscience Institute (China-INI), Beijing, China
| | - Kun Yang
- Department of Evidence-Based Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Feng Ling
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; China International Neuroscience Institute (China-INI), Beijing, China
| | - Yan Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; China International Neuroscience Institute (China-INI), Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China; China International Neuroscience Institute (China-INI), Beijing, China; Department of Interventional Neuroradiology, Capital Medical University, Beijing, China.
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Pryamikov AD, Mironkov AB, Loluev RY, Khripun AI. [Carotid endarterectomy and carotid artery stenting in advanced age patients]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2021; 85:113-117. [PMID: 33560627 DOI: 10.17116/neiro202185011113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The manuscript is devoted to world experience of carotid endarterectomy and carotid artery stenting in advanced age patients. Some authors report the advantages of endovascular surgery in elderly patients while the others prefer carotid endarterectomy. Senile patients (75-80 years old) with asymptomatic internal carotid artery stenosis is one of the most difficult group for the management. This is due to a more complex assessment of perioperative surgical risk, high incidence of complicated atherosclerotic plaques in carotid arteries and dubious benefits of surgery considering short life expectancy and severe comorbidities. Accumulation of experience in the management of advanced age patients should be valuable for either optimizing or individualizing surgical strategy.
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Affiliation(s)
- A D Pryamikov
- Pirogov Russian National Research Medical University, Moscow, Russia.,Buyanov Clinical Hospital, Moscow, Russia
| | - A B Mironkov
- Pirogov Russian National Research Medical University, Moscow, Russia.,Buyanov Clinical Hospital, Moscow, Russia
| | - R Yu Loluev
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A I Khripun
- Pirogov Russian National Research Medical University, Moscow, Russia
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Jones B, Riga C, Bicknell C, Hamady M. Robot-Assisted Carotid Artery Stenting: A Safety and Feasibility Study. Cardiovasc Intervent Radiol 2021; 44:795-800. [PMID: 33447924 PMCID: PMC8060210 DOI: 10.1007/s00270-020-02759-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 12/23/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE Endovascular robotics is an emerging technology within the developing field of medical robotics. This was a prospective evaluation to assess safety and feasibility of robotic-assisted carotid artery stenting. MATERIALS AND METHODS Consecutive cases of carotid artery stenting cases performed over period of 24 months, from May 2015 to October 2016, using the Magellan Robotic System (Hansen, Mountain View, CA) were included. All cases utilised the robotic system to navigate the arch, obtain a stable position in the common carotid artery, followed by manual manipulation of Embolic Protection Devices and self-expandable stents through the robotic catheter. Patients demographics, clinical indications, anatomical features, technical and clinical success, complication rate and hospital stay were prospectively recorded. RESULTS Thirteen patients, 10 males (78.5%), with an average age of 68.7 years were treated. Mean follow up time was 30 months. Ten patients (91%) were symptomatic at presentation. Anatomical indications for endovascular stent insertion were previous open surgery to the neck ± radiotherapy (87.5%) and hostile anatomy for open surgery (12.5%). Technical success was 100% and the robotic system demonstrates enhanced stability during arch and lesion crossing. There were no neurological complications post-operatively. Average hospital stay was 3 days (range 2-6 days) and a change in serum creatinine of -7.8 μmol/L. There was no documented case of in stent restenosis, new or worsening neurology during follow-up. CONCLUSION These results illustrate safety and feasibility of robotic endovascular revascularisation for carotid disease and demonstrates potential to enhance peri-procedural safety through improved control and stability.
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Affiliation(s)
- Ben Jones
- Department of Interventional Radiology, Imperial Health and Academic NHS Trust, London, W2 1NY, UK
| | - Celia Riga
- Department of Surgery and Cancer, Imperial College, London, W2 1NY, UK
| | - Colin Bicknell
- Department of Surgery and Cancer, Imperial College, London, W2 1NY, UK
- Imperial Vascular Unit, St Mary's and Charing Cross Hospitals, Imperial Healthcare NHS Trust, London, UK
| | - Mohamad Hamady
- Department of Interventional Radiology, Imperial Health and Academic NHS Trust, London, W2 1NY, UK.
- Department of Surgery and Cancer, Imperial College, London, W2 1NY, UK.
- Imperial Vascular Unit, St Mary's and Charing Cross Hospitals, Imperial Healthcare NHS Trust, London, UK.
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Feng Y, Bai X, Wang T, Wang Y, Chen Y, Li M, Hua Y, Ling F, Ma Y, Jiao L. Thirty-day outcomes of carotid endarterectomy in the elderly: A 17-year single-center study. J Clin Neurosci 2020; 78:86-90. [PMID: 32622649 DOI: 10.1016/j.jocn.2020.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 06/06/2020] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Carotid endarterectomy (CEA) has been supported as a durable procedure for treating patients with carotid artery stenosis by many randomized controlled trials (RCTs). The aim of this study was to evaluate the 30-day outcomes and risk factors for CEA in elderly patients with a retrospective single-center study. METHODS Our study sample consisted of patients from 2001 to 2017 CEA-targeted Xuanwu Hospital, Capital Medical University data set. The primary outcome was 30-day postoperative incidence of major adverse clinical events (MACEs; death, myocardial infarction (MI) and ipsilateral stroke). Univariable and multivariable analyses were performed to identify high-risk patients and procedural characteristics associated with MACEs. RESULTS A total of 348 elderly patients undergoing CEA for carotid artery stenosis were identified and analyzed. The incidence of postoperative MACEs was 4.6% (16 cases, included 1 death, 14 S, and 1 MI respectively) for elderly patients. Univariate analysis indicated symptomatic lesion (81.3% vs 55.7%, p = 0.044), diabetes mellitus (56.3% vs 26.8%, p = 0.011) and DBP (85.56 ± 11.26 mmHg vs 76.53 ± 9.51 mmHg, p < 0.001) were statistically significant with MACEs. On multivariable analysis, independent predictors of MACEs included diabetes mellitus (DM) (OR = 2.882; 95% CI = 1.005-8.266; P = 0.049) and higher diastolic blood pressure (DBP) (OR = 1.079; 95% CI = 1.025-1.136; P = 0.004). Symptomatic lesion was not an independent risk factor (OR = 2.805; 95% CI = 0.759-10.361; P = 0.122). CONCLUSIONS According to our single-center experience, CEA could be safely performed in elderly patients. Risk factors identified for MACEs in this special group patients were DM and higher DBP.
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Affiliation(s)
- Yao Feng
- Interventional Radiology Diagnosis and Treatment Center, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xuesong Bai
- Interventional Radiology Diagnosis and Treatment Center, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tao Wang
- Interventional Radiology Diagnosis and Treatment Center, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yabing Wang
- Interventional Radiology Diagnosis and Treatment Center, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yanfei Chen
- Interventional Radiology Diagnosis and Treatment Center, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Meng Li
- Interventional Radiology Diagnosis and Treatment Center, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yang Hua
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Feng Ling
- Interventional Radiology Diagnosis and Treatment Center, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yan Ma
- Interventional Radiology Diagnosis and Treatment Center, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Liqun Jiao
- Interventional Radiology Diagnosis and Treatment Center, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
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Mazzaccaro D, Modafferi A, Malacrida G, Nano G. Assessment of long-term survival and stroke after carotid endarterectomy and carotid stenting in patients older than 80 years. J Vasc Surg 2019; 70:522-529. [DOI: 10.1016/j.jvs.2018.10.121] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 10/24/2018] [Indexed: 12/13/2022]
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Prevention and Treatment of Acute Stroke in the Nonagenarians and Beyond: Medical and Ethical Issues. Curr Treat Options Neurol 2019; 21:27. [PMID: 31065827 DOI: 10.1007/s11940-019-0567-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE OF REVIEW As one of the fastest growing portions of the population, nonagenarians will constitute a significant percentage of the stroke patient population in the near future. Nonagenarians are nevertheless not specifically targeted by most clinical guidelines. In this review, we aimed to summarise the available evidence guiding stroke prevention and treatment in this age group. RECENT FINDINGS Several recent observational studies have shown that the benefits of anticoagulation for the oldest old patients with atrial fibrillation may outweigh the bleeding risk. A sub-analysis of the IST-3 trial has shown for the first time that thrombolysis treatment in acute ischaemic stroke may be beneficial and safe even in octogenarian patients and older. Several recent observational studies have assessed thrombolysis in nonagenarians. The latest of these has shown better disability outcomes without increased rates of symptomatic intracerebral haemorrhage with thrombolysis. Nonagenarian stroke patients may benefit from similar preventative and therapeutic strategies as their younger counterparts. A few important exceptions include primary prevention using aspirin or statins. Patient selection is nevertheless essential given the increased adverse event rates. Patient preference should play a key role in the decision-making process. Clinical trials including more nonagenarian patients are required to yield more robust evidence.
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Elhfnawy AM, Heuschmann PU, Pham M, Volkmann J, Fluri F. Stenosis Length and Degree Interact With the Risk of Cerebrovascular Events Related to Internal Carotid Artery Stenosis. Front Neurol 2019; 10:317. [PMID: 31024420 PMCID: PMC6465418 DOI: 10.3389/fneur.2019.00317] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 03/13/2019] [Indexed: 12/23/2022] Open
Abstract
Background and Purpose: Internal carotid artery stenosis (ICAS)≥70% is a leading cause of ischemic cerebrovascular events (ICVEs). However, a considerable percentage of stroke survivors with symptomatic ICAS (sICAS) have <70% stenosis with a vulnerable plaque. Whether the length of ICAS is associated with high risk of ICVEs is poorly investigated. Our main aim was to investigate the relation between the length of ICAS and the development of ICVEs. Methods: In a retrospective cross-sectional study, we identified 95 arteries with sICAS and another 64 with asymptomatic internal carotid artery stenosis (aICAS) among 121 patients with ICVEs. The degree and length of ICAS as well as plaque echolucency were assessed on ultrasound scans. Results: A statistically significant inverse correlation between the ultrasound-measured length and degree of ICAS was detected for sICAS≥70% (Spearman correlation coefficient ρ = -0.57, p < 0.001, n = 51) but neither for sICAS<70% (ρ = 0.15, p = 0.45, n = 27) nor for aICAS (ρ = 0.07, p = 0.64, n = 54). The median (IQR) length for sICAS<70% and ≥70% was 17 (15-20) and 15 (12-19) mm (p = 0.06), respectively, while that for sICAS<90% and sICAS 90% was 18 (15-21) and 13 (10-16) mm, respectively (p < 0.001). Among patients with ICAS <70%, a cut-off length of ≥16 mm was found for sICAS rather than aICAS with a sensitivity and specificity of 74.1% and 51.1%, respectively. Irrespective of the stenotic degree, plaques of the sICAS compared to aICAS were significantly more often echolucent (43.2 vs. 24.6%, p = 0.02). Conclusion: We found a statistically insignificant tendency for the ultrasound-measured length of sICAS<70% to be longer than that of sICAS≥70%. Moreover, the ultrasound-measured length of sICAS<90% was significantly longer than that of sICAS 90%. Among patients with sICAS≥70%, the degree and length of stenosis were inversely correlated. Larger studies are needed before a clinical implication can be drawn from these results.
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Affiliation(s)
| | - Peter U. Heuschmann
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Mirko Pham
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital of Würzburg, Würzburg, Germany
| | - Jens Volkmann
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Felix Fluri
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
- Department of Neurology, Kantonssptial St. Gallen, St. Gallen, Switzerland
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