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Abstract
Background: Platelet inhibitory therapy is prescribed to prevent arterial thromboembolism in patients with atherosclerotic disease. Although taken by millions of people, around 30% are resistant to the treatment they are being prescribed. Aims: To determine whether symptoms of cerebral ischemia, or pre-operative cerebral emboli, in patients admitted for a carotid endarterectomy were associated with resistance to aspirin or clopidogrel. Methods: Venous blood from 133 patients immediately before carotid endarterectomy (CEA) was analyzed for resistance to aspirin and clopidogrel by multiplate impedance aggregometry. The number of emboli/hour entering the ipsilateral middle cerebral artery was counted by transcranial Doppler (TCD) on the day before surgery in 33 of these patients. Results: Resistance was found in 21 (26.3%) of 100 patients taking aspirin and 14 (42%) of 33 taking clopidogrel. Mean (sd) residual platelet aggregation was significantly higher at 41.9(32) Au in patients who had suffered recent symptoms of cerebral ischemia compared with 30.8(16) Au in asymptomatic patients (p = 0.012). Residual platelet aggregation also correlated significantly with the number of emboli/hour counted by TCD in the ipsilateral middle cerebral artery (r = 0.45, p = 0.009). Conclusion: Antiplatelet resistance was associated with the frequency of cerebral emboli and recent symptoms of cerebral ischemia in patients with carotid disease. Definitive clinical studies are needed to explore whether testing for antiplatelet resistance should be undertaken routinely in patients starting platelet inhibitory therapy for cardiovascular disease.
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Affiliation(s)
- Stephen T E Ball
- Academic Surgery Unit, Institute of Cardiovascular Sciences, 5292University of Manchester, Manchester, United Kingdom
| | - Rachael Taylor
- Academic Surgery Unit, Institute of Cardiovascular Sciences, 5292University of Manchester, Manchester, United Kingdom
| | - Charles N McCollum
- Academic Surgery Unit, Institute of Cardiovascular Sciences, 5292University of Manchester, Manchester, United Kingdom
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Das AS, Regenhardt RW, LaRose S, Monk AD, Castro PM, Sheriff FG, Sorond FA, Vaitkevicius H. Microembolic Signals Detected by Transcranial Doppler Predict Future Stroke and Poor Outcomes. J Neuroimaging 2020; 30:882-889. [PMID: 32648610 DOI: 10.1111/jon.12749] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 06/14/2020] [Accepted: 06/16/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND PURPOSE Although transcranial Doppler detects microembolic signals (MES) in numerous settings, the practical significance of such findings remains unclear. METHODS Clinical information from ischemic stroke or transient ischemic attack patients (n = 248) who underwent embolic monitoring from January 2015 to December 2018 was obtained. RESULTS MES were found in 15% of studies and ischemic recurrence was seen in 11% of patients (over 7 ± 6 days). Patients with MES had more lacunes than those without MES (1 ± 3 vs. 1 ± 2, P = .016), were more likely to have ischemic recurrence (37% vs. 6%, P < .001), undergo a future revascularization procedure (26% vs. 10%, P = .005), have a longer length of stay (9 vs. 4 days, P = .043), and have worse functional disability at discharge (modified Rankin Scale 3-6, 66% vs. 34%, P < .001). After controlling for several relevant cofactors, patients with MES were more likely to have ischemic recurrence (HR 4.90, 95% CI 2.16-11.09, P < .001), worse functional disability (OR 3.31, 95% CI 1.22-8.99, P = .019), and longer length of stays (β = .202, P < .001). CONCLUSIONS MES may help to risk stratify patients as their presence is associated with ischemic recurrence and worse outcomes.
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Affiliation(s)
- Alvin S Das
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Robert W Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Sarah LaRose
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Andrew D Monk
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Pedro M Castro
- Department of Neurology, Centro Hospital Universitário São João, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Faheem G Sheriff
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Farzaneh A Sorond
- Department of Neurology, Northwestern Memorial Hospital, Feinberg School of Medicine, Chicago, IL
| | - Henrikas Vaitkevicius
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Girardi LN, Ohmes LB. Is Less More or Is More Less? Semin Thorac Cardiovasc Surg 2017; 29:49-50. [PMID: 28683997 DOI: 10.1053/j.semtcvs.2017.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2017] [Indexed: 11/11/2022]
Abstract
Although aortic hemiarch replacement without the use of deep hypothermic circulatory arrest may be feasible in experienced centers, manipulation of the aortic arch and great vessels is of concern. Additional research is necessary before widespread adoption of this technique.
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Affiliation(s)
- Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York.
| | - Lucas B Ohmes
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
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Chandra A, Stone CR, Li WA, Geng X, Ding Y. The cerebral circulation and cerebrovascular disease II: Pathogenesis of cerebrovascular disease. Brain Circ 2017; 3:57-65. [PMID: 30276306 PMCID: PMC6126265 DOI: 10.4103/bc.bc_11_17] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 05/20/2017] [Accepted: 06/01/2017] [Indexed: 12/12/2022] Open
Abstract
In this paper, we review the cerebral circulation and cerebrovascular disease (CVD) with an overview of the major types of CVD pathogenesis. These, as categorized here, are as follows: occlusive injury intrinsic to blood vessels, occlusive injury extrinsic to blood vessels, cerebral hypoperfusion, and cerebral hemorrhage. Following an overview of each of these categories, we conclude with a discussion of cerebral edema to illustrate how the pathological origins we covered can progress clinically. The content of this paper sets the stage for the detailed, clinically oriented discussion of stroke with which our series culminates in its subsequent Part III.
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Affiliation(s)
- Ankush Chandra
- Department of Neurological Surgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Christopher R Stone
- Department of Neurological Surgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - William A Li
- Department of Neurological Surgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Xiaokun Geng
- Department of Neurological Surgery, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Yuchuan Ding
- Department of Neurological Surgery, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
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Abstract
Children experiencing severe neurological deficit due to acute ischemic stroke may benefit from endovascular intervention. The authors describe the use of mechanical thrombectomy in the treatment of embolic occlusion secondary to an atrial myxoma in a pediatric patient. This case involved an 11-year-old boy with a history notable for Raynaud syndrome and a distal extremity rash who presented to the emergency department with dense hemiparesis secondary to thromboembolic occlusion of the M1 segment of the middle cerebral artery. Following mechanical thrombectomy, the patient's pediatric National Institutes of Health Stroke Scale score improved from a 16 to a 7. In the setting of acute pediatric stroke due to atrial myxoma emboli, mechanical thrombectomy may be a first-line therapy.
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Naranjo D, Arkuszewski M, Rudzinski W, Melhem ER, Krejza J. Brain ischemia in patients with intracranial hemorrhage: pathophysiological reasoning for aggressive diagnostic management. Neuroradiol J 2013; 26:610-28. [PMID: 24355179 PMCID: PMC4202872 DOI: 10.1177/197140091302600603] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 10/15/2013] [Indexed: 11/15/2022] Open
Abstract
Patients with intracranial hemorrhage have to be managed aggressively to avoid or minimize secondary brain damage due to ischemia, which contributes to high morbidity and mortality. The risk of brain ischemia, however, is not the same in every patient. The risk of complications associated with an aggressive prophylactic therapy in patients with a low risk of brain ischemia can outweigh the benefits of therapy. Accurate and timely identification of patients at highest risk is a diagnostic challenge. Despite the availability of many diagnostic tools, stroke is common in this population, mostly because the pathogenesis of stroke is frequently multifactorial whereas diagnosticians tend to focus on one or two risk factors. The pathophysiological mechanisms of brain ischemia in patients with intracranial hemorrhage are not yet fully elucidated and there are several important areas of ongoing research. Therefore, this review describes physiological and pathophysiological aspects associated with the development of brain ischemia such as the mechanism of oxygen and carbon dioxide effects on the cerebrovascular system, neurovascular coupling and respiratory and cardiovascular factors influencing cerebral hemodynamics. Consequently, we review investigations of cerebral blood flow disturbances relevant to various hemodynamic states associated with high intracranial pressure, cerebral embolism, and cerebral vasospasm along with current treatment options.
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Affiliation(s)
- Daniel Naranjo
- Department of Diagnostic Radiology of the University of Maryland, Division of Clinical Research; Baltimore, Maryland, USA
| | - Michal Arkuszewski
- Department of Neurology, Medical University of Silesia, Central University Hospital; Katowice, Poland
| | - Wojciech Rudzinski
- Department of Cardiology, Robert Packer Hospital; Sayre, Pennsylvania USA
| | - Elias R. Melhem
- Department of Diagnostic Radiology of the University of Maryland, Division of Clinical Research; Baltimore, Maryland, USA
| | - Jaroslaw Krejza
- Department of Diagnostic Radiology of the University of Maryland, Division of Clinical Research; Baltimore, Maryland, USA
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Siewiorek GM, Krafty RT, Wholey MH, Finol EA. The association of clinical variables and filter design with carotid artery stenting thirty-day outcome. Eur J Vasc Endovasc Surg 2011; 42:282-91. [PMID: 21530332 PMCID: PMC3157584 DOI: 10.1016/j.ejvs.2011.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2010] [Accepted: 04/02/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Patient and device selection are important for the success of carotid artery stenting (CAS). We hypothesize that distal protection filter (DPF) design characteristics that minimize blood flow resistance and maximize capture efficiency are associated with the absence of transient ischemic attack (TIA), stroke and neurologic-related death after 30 days. METHODS Records from 208 patients were reviewed retrospectively. Filter design characteristics were quantified previously in our laboratory. The association between risk factors and design characteristics with 30-day outcome was quantified using univariate analysis. RESULTS The 30-day all-cause stroke and death rate was 8.7% (asymptomatic: 7.7%, symptomatic: 10.6%). Five DPFs were used in the study: Accunet (41.3%), Angioguard (33.2%), FilterWire (24%), Emboshield (1%), and Spider (.5%). Diabetes (P = .04) and prior carotid endarterectomy (CEA, P = .03) were associated with adverse outcome. Prior stroke (P = .01) and prior CEA (P = .04) were significant for peri-procedural stroke. Design characteristics such as capture efficiency were associated with favorable outcomes. CONCLUSIONS Patients with prior CEA or stroke are more likely to have unfavorable CAS outcomes after 30 days. Filters with high capture efficiency may yield the best clinical results. Analysis of the effect of design characteristics on CAS outcome should aid the design of future devices.
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Affiliation(s)
- Gail M. Siewiorek
- Biomedical Engineering Department Carnegie Mellon University 1210 Hamburg Hall 5000 Forbes Avenue Pittsburgh, PA 15213 USA
| | - Robert T. Krafty
- Department of Statistics University of Pittsburgh 2702 Cathedral of Learning Pittsburgh, PA 15260 USA
| | - Mark H. Wholey
- University of Pittsburgh Medical Center – Shadyside 5230 Centre Avenue, Suite 603 Pittsburgh, PA 15232 USA
| | - Ender A. Finol
- Biomedical Engineering Department Carnegie Mellon University 1210 Hamburg Hall 5000 Forbes Avenue Pittsburgh, PA 15213 USA
- Institute for Complex Engineered Systems and Department of Mechanical Engineering 1205 Hamburg Hall 5000 Forbes Avenue Carnegie Mellon University Pittsburgh, PA 15213 USA
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Abstract
We describe a case of infective endocarditis due to Moraxella lacunata involving the native mitral and aortic valves, complicated by cerebral emboli and resultant hemiparesis. The patient was treated with ceftriaxone and gentamicin and improved. This appears to be the first case reported in the medical literature of native multivalvular endocarditis produced by this rare organism.
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Affiliation(s)
- S Dasari
- Department of Medicine, Kasturba Medical College, Manipal
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Bostan M, Kanat A, Sen M, Kazdal H, Bostan H. Cerebral embolism following thrombolytic therapy for acute myocardial infarction: the second reported case. Cardiovasc J Afr 2010; 21:155-7. [PMID: 20532455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
ST-elevation myocardial infarction (STEMI), caused by acute occlusion of the infarct-related coronary artery, is an emergency condition. The primary therapy is restoration of full antegrade flow by either percutaneus coronary intervention (PCI) or thrombolytic therapy (TT). Although primary PCI is superior to TT in patients with STEMI, there are many limitations in clinical practice. TT decreases mortality in STEMI patients, but as experience with thrombolytic agents grows, the potential risks of serious side effects become more apparent. The major complications are bleeding, hypotension and skin rash. We report on a case of cerebrovascular accident (CVA) caused by cerebral emboli following TT. We concluded that the fact that the patient was in arterial fibrillation (AF) was a major contributing factor to her CVA. This is an extremely rare condition, and our case appears to be the second one reported on in the literature.
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