Carotid Circulation Research Articles

Акустические стволовые и когнитивные вызванные потенциалы при хроническом нарушении мозгового кровообращения

Current research aimed to investigate informational content of auditory evoked potentials (EP) (acoustic brainstem and cognitive – mismatch negativity) in assessment of brain functional status and cognitive functions in patients with chronic cerebrovascular disease (chronic CVD). Clinical and neurophysiological examination was performed for 33 patients. Group 1 included 12 patients with chronic CVD in carotid circulation, mean age 61,2 ± 6,3 years old; group 2 included 11 patients with chronic CVD in vertebrobasilar circulation, mean age 62,4 ± 8,0 years old; group 3 (control) - 10 patients without cerebrovascular diseases), mean age 54,6±6,4 years old. For registration of acoustic brainstem EP two series of 1000 stimuli were applied (“click” type, duration 0,1 ms, intensity 65 dB above patient’s hearing level, frequency 10 Hz). Mismatch negativity (MMN) was registered in classic odd-ball paradigm (standard stimulus – a sinusoidal tone with 1000 Hz frequency, deviant – with 900 Hz frequency; interstimulus interval – 500 ms). Results. According to results of MMSE, FAB, test of 10 words repetition and Schulte tables patients with chronic CVD, independently of predominantly affected vascular pool, demonstrated cognitive impairment as compared to control group. In patients with chronic CVD no statistically significant differences of acoustic brainstem EP were revealed, however, MMN amplitude was decreased in comparison with control group. It indicates a shortened lifetime of memory traces and deficit in involuntary attention switching in chronic CVD. Investigation of cognitive EP MMN is informative and can be used in assessment of cognitive impairment.

Recent guidelined for the early endovascular management of patients with acute ischemic stroke and practical aspects of their implementation

Objective — to estimate safety and effectiveness of intra-arterial treatment for acute ischemic stroke in the interventional radiology department of multiprofile hospital. Materials and methods. Urgent endovascular treatment was applied at 15 patients with acute ischemic stroke in carotid circulation during 2015–2017. Mechanical intra-arterial therapy with thrombectomy by stent-retrievers and thromboaspiration was used at accordingly six and two recent cases (during 2017); in 7 cases intra-arterial thrombolysis was the treatment option (2015–2016). Results. The article consist brief review of literature about acute ischemic stroke treatment and discussion concerning results of treatment of selected patients. Mechanical thrombectomy or thromboaspiration were effective in 75.0 % of cases with good recanalization rate opposite to 42.9 % at 7 patients treated by either intra-arterial or bridging thrombolysis with rt-PA. Unexpected technical failures of mechanical thrombectomy regarding recent clinical guidelines for ischemic stroke management following are discussed on example of 2 clinical cases. Conclusions. Endovascular treatment of ischemic stroke has a high safety and well-known efficacy. It became evident at our patients that following current management guidelines for thrombectomy with stent-retrievers or thromboaspiration after thrombotic occlusions of extracranial and proximal segments of intracranial arteries allowed attaining in 2017 reperfusion rate 2b/3 Modified Treatment in Cerebral Ischaemia Scale in majority of cases. Intra-arterial thrombolysis contributed to the reperfusion rate 2b/3 on the Modified Treatment in Cerebral Ischaemia scale just in 42.9 % of cases, which indicates its lower effectiveness.

Incomplete circle of Willis is associated with a higher incidence of neurologic events during carotid eversion endarterectomy without shunting

ObjectiveA complete circle of Willis (CoW) is considered an important collateral network to maintain blood flow during cross-clamping in carotid endarterectomy (CEA). The aim of this study was to evaluate the impact of an incomplete CoW with isolated middle cerebral artery (iMCA) on immediate neurologic events (INEs) after CEA. MethodsWe prospectively collected the clinical data and outcomes of 902 patients who underwent CEA under general anesthesia between 2013 and 2015. All patients had preoperative computed tomography angiography of the extracranial and intracranial cerebral circulation. Indications were asymptomatic (52%) and symptomatic (48%) carotid artery disease. Patients who had CEA with shunt (n = 35) and those with inadequate intracranial imaging to assess CoW were excluded (n = 322) only. Computed tomography angiography images were reviewed retrospectively and independently by two vascular radiologists who were blinded for treatment outcomes. Imaging assessment included the vertebral and carotid circulation and each segment of the CoW, which was classified as normal, hypoplastic (diameter < 0.8 mm) or absent. The ipsilateral MCA was considered isolated if there was an absence of the anterior and posterior communicating branches from the contralateral carotid or posterior circulations. INE was defined as any transient ischemic attack (TIA) and stroke diagnosed immediately after the procedure. ResultsOf the 545 included patients (331 males; mean age, 69 ± 8 years), 12 (2.2%) had a stroke in the postoperative period. There were 20 INEs (8 strokes and 12 TIAs). A complete CoW was rare; it was only detected in 19 patients (3.5%) and an iMCA was found in 34 patients (6.3%). When at least one collateral circulation was complete (in 330 patients), we observed only four INEs (1.2%). Of the 34 patients with an iMCA, 8 (24%) had INE (6 TIAs and 2 strokes). Overall, iMCA was an independent predictor of INEs (odds ratio, 11.12; 95% confidence interval, 3.57-35.87; P < .001). With logistic regression, the model included hypertension, smoking, diabetes, hyperlipidemia, carotid clamping time (minutes), contralateral significant internal carotid artery stenosis of greater than 90%, ipsilateral significant internal carotid artery stenosis of greater than 90%, preoperative symptoms in 6 months, and iMCA; above iMCA only symptomatic patients had significant risk (odds ratio, 3.34; 95% confidence interval, 1.19-9.73; P = .02), whereas all other parameters were not significant. ConclusionsAn iMCA carries more than a 10-fold higher the risk of INEs after CEA with cross-clamping without shunt protection. In these patients, routine shunting is recommended to prevent INEs.

Long-Term Outcomes After Carotid Endarterectomy: The Experience of an Average-Volume Surgeon

Long-term outcome data for patients undergoing carotid endarterectomy (CEA) are lacking. As most of the published literature on CEA outcomes has been from high-volume providers, we wanted to investigate theoutcomes of an average-volume cerebrovascular neurosurgeon. We reviewed a single neurosurgeon's experience with CEA focusing on long-term outcomes. Most procedures (99.0%) were performed with primary closure of the arteriotomy. We studied 192 CEAs performed between 1998 and 2017, 77% for symptomatic disease. Two patients (1%) experienced immediate postoperative stroke. During an average follow-up of 53 months (range, 0-205 months), 2 more patients (1%) experienced ipsilateral carotid circulation stroke, and 5 patients (2.6%) experienced ipsilateral transient ischemic attacks. Five patients (2.6%) experienced contralateral transient ischemic attacks, and 6 (3.1%) experienced contralateral stroke. There were also 3 cases of (1.6%) hemorrhagic stroke and 6 cases (3.1%) of vertebrobasilar circulation stroke. The rate of ipsilateral stroke-free survival was 98.4% at 5 years post-CEA, 97.9% at 10 years post-CEA, and 97.9% at 15 years post-CEA. The rate of ipsilateral restenosis-free survival was 97.9% at 5years post-CEA, 96.8% at 10 years post-CEA, and 96.8% at 15 years post-CEA. Six patients (3.1%) experienced restenosis >70% during follow-up. Two of these patients underwent carotid artery stenting. Almost all patients (>95%) were maintained on an antiplatelet medication and statin. In the hands of an average-volume cerebrovascular neurosurgeon, CEA can provide durable protection from recurrent stroke in the ipsilateral carotid distribution that extends beyond 15 years. Thus, this procedure should be considered the gold standard against which other revascularization modalities should be evaluated.

Association between Apolipoproteins AI and B and Ultrasound Indicators of Carotid Atherosclerosis.

Apolipoproteins A-I and B (apoA-I and apoB) may be better indicators of the risk of cardiovascular and cerebrovascular diseases than conventional risk factors (RFs). The onset of ischemic stroke (IS) may be preceded by the development of atherosclerotic changes in carotid arteries, which can be detected by ultrasound. Only a certain % of patients with IS have an (underlying) carotid etiology. The aim of our study was to determine the association between ultrasound indicators of carotid atherosclerosis and the presence of apolipoproteins and other biomarkers in patients with IS. The study included 120 patients with clinically first, non-cardioembolic ischemic stroke in the carotid circulation. For all patients the following data were recorded: risk factors (hypertension, diabetes, hyperlipoproteinemia, smoking, obesity, metabolic syndrome, (MetS) hyperhomocysteinemia and inflammation), and levels of blood pressure, glucose, glycosylated hemoglobin, lipids, apoA-I and apoB apolipoproteins, body mass index, homocysteine, and C-reactive protein (CRP). Carotid duplex ultrasound was used to measure carotid intima media thickness (cIMT) and determine the presence of an unstable (hypoechogenic) plaque. The most significant associations were found between cIMT and older age (β=0.230; p=0.006), lower concentrations of apoA-I (β=-0.244; p=0.008) and a higher apoB/apoA-I ratio (β=0.247; p=0.007). The presence of a hypoechogenic plaque was most significantly associated with increased concentrations of apoB (OR=2.29; 95% CI=4.9-173.5; p<0.0001), the presence of MetS (OR=9.2; 95% CI=2.9-29.2; p<0.0001) and elevated CRP (OR=2.7; 95% CI=1.1-6.9; p = 0.046). Among RFs and their biomarkers, apoA-I, apoB and the apoB/apoA-I ratio showed strong association with ultrasound indicators of carotid atherosclerosis in IS patients.

Clinical features, course, and outcomes of a UK cohort of pediatric moyamoya.

To describe characteristics and course of a large UK cohort of children with moyamoya from multiple centers and examine prognostic predictors. Retrospective review of case notes/radiology, with use of logistic regression to explore predictors of outcome. Eighty-eight children (median presentation age 5.1 years) were included. Thirty-six presented with arterial ischemic stroke (AIS) and 29 with TIA. Eighty had bilateral and 8 unilateral carotid circulation disease; 29 patients had posterior circulation involvement. Acute infarction was present in 36/176 hemispheres and chronic infarction in 86/176 hemispheres at the index presentation. Sixty-two of 82 with symptomatic presentation had at least one clinical recurrence. Fifty-five patients were treated surgically, with 37 experiencing fewer recurrences after surgery. Outcome was categorized as good using the Recovery and Recurrence Questionnaire in 39/85 patients. On multivariable analysis, presentation with TIA (odds ratio [OR] 0.09, 95% confidence interval [CI] 0.02-0.35), headache (OR 0.10, 95% CI 0.02-0.58), or no symptoms (OR 0.08, 95% CI 0.01-0.68) was less likely to predict poor outcome than AIS presentation. Posterior circulation involvement predicted poor outcome (OR 4.22, 95% CI 1.23-15.53). Surgical revascularization was not a significant predictor of outcome. Moyamoya is associated with multiple recurrences, progressive arteriopathy, and poor outcome in half of patients, especially with AIS presentation and posterior circulation involvement. Recurrent AIS is rare after surgery. Surgery was not a determinant of overall outcome, likely reflecting surgical case selection and presentation clinical status.

Patterns of Acute Ischemic Strokes After Carotid Endarterectomy and Therapeutic Implications.

Acute ischemic strokes following surgical treatment of carotid stenosis lead to substantial disability and mortality, and vascular mechanisms underlying their development are not fully elucidated. The goal of this study was to analyze the topographic patterns of acute ischemic stroke following carotid endarterectomy (CEA) on diffusion-weighted and perfusion-weighted magnetic resonance imaging (MRI). Data were retrospectively collected from consecutive patients who underwent CEA and developed postoperative acute ischemic stroke. Based on the MRI data sets, the lesion patterns of acute stoke were characterized. Morphology of the circle of Willis, the 3-D time-of-flight (3D-TOF) of the cerebral arteries, and status of the carotid circulation were also analyzed in order to determine the vascular mechanisms involved in stroke development. Between January 2008 and May 2015, 821 patients were treated surgically for a symptomatic or asymptomatic carotid stenosis at the University Hospital of Nice. Nineteen (2.3%) patients had an acute ischemic stroke after surgery. Among them, 11 (57.9%) patients had a territorial infarction and 8 (42.1%) patients had an internal watershed infarction, cortical watershed infarction, or mixed border zone infarction. According to imaging data sets, embolic mechanism of stroke was reported for 12 (63.2%) patients, hemodynamic mechanism for 2 (10.5%) patients, and mixed mechanism for 5 (26.3%) patients. An asymmetry on 3D-TOF was observed in 60% and 50% of patients with hemodynamic and mixed stroke and in 25% of patients with embolic stroke. The latter 2 patients with embolic stroke underwent successful mechanical thrombectomy using stent-retriever devices. In this cohort, embolic mechanism leading to postoperative stroke was more frequently observed than hemodynamic mechanism. Immediate characterization of the cerebral lesion by postoperative brain MRI is of utmost importance because it may rapidly identify patients eligible for treatments such as mechanical thrombectomy.

Effects of organic and inorganic nitrate on aortic and carotid haemodynamics in heart failure with preserved ejection fraction.

To assess the haemodynamic effects of organic vs. inorganic nitrate administration among patients with heart failure with preserved ejection fraction (HFpEF). We assessed carotid and aortic pressure-flow relations non-invasively before and after the administration of 0.4 mg of sublingual nitroglycerin (n = 26), and in a separate sub-study, in response to 12.9 mmoL of inorganic nitrate (n = 16). Nitroglycerin did not consistently reduce wave reflections arriving at the proximal aorta (change in real part of reflection coefficient, 1st harmonic: -0.09; P = 0.01; 2nd harmonic: -0.045, P = 0.16; 3rd harmonic: +0.087; P = 0.05), but produced profound vasodilatation in the carotid territory, with a significant reduction in systolic blood pressure (133.6 vs. 120.5 mmHg; P = 0.011) and a marked reduction in carotid bed vascular resistance (19 580 vs. 13078 dynes · s/cm5 ; P = 0.001) and carotid characteristic impedance (3440 vs. 1923 dynes · s/cm5 ; P = 0.002). Inorganic nitrate, in contrast, consistently reduced wave reflections across the first three harmonics (change in real part of reflection coefficient, 1st harmonic: -0.12; P = 0.03; 2nd harmonic: -0.11, P = 0.01; 3rd harmonic: -0.087; P = 0.09) and did not reduce blood pressure, carotid bed vascular resistance, or carotid characteristic impedance (P = NS). Nitroglycerin produces marked vasodilatation in the carotid circulation, with a pronounced reduction in blood pressure and inconsistent effects on central wave reflections. Inorganic nitrate, in contrast, produces consistent reductions in wave reflections, and unlike nitroglycerin, it does so without significant hypotension or cerebrovascular dilatation. These haemodynamic differences may underlie the different effects on exercise capacity and side effect profile of inorganic vs. organic nitrate in HFpEF.

Basicranium of an elasmosaurid plesiosaur from the Campanian of European Russia

Zverkov, N.G., Averianov, A.O. & Popov E.V., April 2017. Basicranium of an elasmosaurid plesiosaur from the Campanian of European Russia. Alcheringa 42, 528-542. ISSN 0311-5518 The braincase of elasmosaurid plesiosaurs is poorly known. Here, we describe the exceptionally well-preserved elasmosaurid basicranium from the Rybushka Formation (lower Campanian) of Saratov Province, Russia. The material provides new anatomical information and peculiar features: single anterior foramen for the cerebral carotid arteries, anteroposteriorly elongated sella turcica and deep canal on the basioccipital process. This allow us to reconstruct a carotid circulation in plesiosaurs and propose new basicranial features (anteroposteriorly elongated sella turcica and single anterior foramen for the cerebral carotids), which could be potentially synapomorphic for a clade within the Elasmosauridae. Nikolay G. Zverkov* [ zverkovnik@mail.ru ], Department of Palaeontology, Geological Faculty, Lomonosov Moscow State University, 1 Leninskie Gory, 119991 Moscow; Laboratory of Phanerozoic Stratigraphy, Department of Stratigraphy, Geological Institute of the Russian Academy of Sciences, Pyzhevsky lane 7, 119017 Moscow, Russia; Alexander O. Averianov [ dzharakuduk@mail.ru ], Zoological Institute of the Russian Academy of Sciences, Universitetskaya Emb. 1, Saint Petersburg 199034; Department of Sedimentary Geology, Geological Faculty, Saint Petersburg State University, 16 liniya VO 29, 199178 Saint Petersburg, Russia; Evgeny V. Popov [ elasmodus74@gmail.com ], Department of Historical Geology and Paleontology, Geological Faculty, Saratov State University, 83 Astrakhanskaya Str., 410012 Saratov; Institute of Geology and Petroleum Technology, Kazan Federal University, Kremlevskaya Str. 4/5, 420008 Kazan, Russia.

Primary Angiitis of the Central Nervous System: Magnetic Resonance Imaging Spectrum of Parenchymal, Meningeal, and Vascular Lesions at Baseline.

Primary angiitis of the central nervous system remains challenging. To report an overview and pictorial review of brain magnetic resonance imaging findings in adult primary angiitis of the central nervous system and to determine the distribution of parenchymal, meningeal, and vascular lesions in a large multicentric cohort. Adult patients from the French COVAC cohort (Cohort of Patients With Primary Vasculitis of the Central Nervous System), with biopsy or angiographically proven primary angiitis of the central nervous system and brain magnetic resonance imaging available at the time of diagnosis were included. A systematic imaging review was performed blinded to clinical data. Sixty patients met inclusion criteria. Mean age was 45 years (±12.9). Patients initially presented focal deficit(s) (83%), headaches (53%), cognitive disorder (40%), and seizures (38.3%). The most common magnetic resonance imaging finding observed in 42% of patients was multiterritorial, bilateral, distal acute stroke lesions after small to medium artery distribution, with a predominant carotid circulation distribution. Hemorrhagic infarctions and parenchymal hemorrhages were also frequently found in the cohort (55%). Acute convexity subarachnoid hemorrhage was found in 26% of patients and 42% demonstrated pre-eminent leptomeningeal enhancement, which is found to be significantly more prevalent in biopsy-proven patients (60% versus 28%; P=0.04). Seven patients had tumor-like presentations. Seventy-seven percent of magnetic resonance angiographic studies were abnormal, revealing proximal/distal stenoses in 57% and 61% of patients, respectively. Adult primary angiitis of the central nervous system is a heterogenous disease, with multiterritorial, distal, and bilateral acute stroke being the most common pattern of parenchymal lesions found on magnetic resonance imaging. Our findings suggest a higher than previously thought prevalence of hemorrhagic transformation and other hemorrhagic manifestations.

Smoking, Smoking Cessation, and Measures of Subclinical Atherosclerosis in Multiple Vascular Beds in Japanese Men.

BackgroundSmoking is an overwhelming, but preventable, risk factor for cardiovascular diseases (CVD), although smoking prevalence remains high in developed and developing countries in East Asia.Methods and ResultsIn a population‐based sample of 1019 Japanese men aged 40 to 79 years, without CVD, we examined cross‐sectional associations of smoking status, cumulative pack‐years, daily consumption, and time since cessation, with subclinical atherosclerosis at 4 anatomically distinct vascular beds, including coronary artery calcification, carotid intima‐media thickness (CIMT) and plaque, aortic artery calcification (AoAC), and ankle‐brachial index. Current, former, and never smoking were present in 32.3%, 50.0%, and 17.7%, respectively. Compared to never smokers, current smokers had significantly higher risks of subclinical atherosclerosis in all 4 circulations (eg, odds ratios for coronary artery calcification >0, 1.79 [95% CIs, 1.16–2.79]; CIMT >1.0 mm, 1.88 [1.02–3.47]; AoAC >0, 4.29 [2.30–7.97]; and ankle‐brachial index <1.1, 1.78 [1.16–2.74]) and former smokers did in carotid and aortic circulations (CIMT >1.0 mm, 1.94 [1.13–3.34]; and AoAC >0, 2.55 [1.45–4.49]). Dose–response relationships of pack‐years and daily consumption, particularly with CIMT, carotid plaque, AoAC, and ankle‐brachial index, were observed among both current and former smokers, and even a small amount of pack‐years or daily consumption among current smokers was associated with coronary artery calcification and AoAC, whereas time since cessation among former smokers was linearly associated with lower burdens of all atherosclerotic indices.ConclusionsCigarette smoking was strongly associated with subclinical atherosclerosis in multiple vascular beds in Japanese men, and these associations attenuated with time since cessation.

Treatment of Distal Anterior Circulation Aneurysms With the Pipeline Embolization Device: A US Multicenter Experience.

Utilization of the Pipeline embolization device (PED) to treat distal carotid circulation aneurysms has not been well studied. To report the collective experience of using PED to treat distal anterior circulation aneurysms. We retrospectively reviewed clinical and radiographic records of all patients who underwent Pipeline embolization of distal anterior circulation aneurysms at 10 US neurosurgical centers between 2011 and 2013. Twenty-eight patients (mean age 51.7 years; 18 women) with 28 aneurysms were included in the analyses. Fifteen aneurysms were fusiform, 5 dissecting, and 8 saccular. Average aneurysm size was 12.3 mm; 7 were giant. Twenty aneurysms were located along the middle cerebral artery, 6 along the anterior cerebral artery, and 2 along the anterior communicating artery. PED deployment was successful in 27 patients, with coils utilized in 6 cases. Clinical follow-up was available for an average of 10.7 months (range 3-26). Twenty-seven patients had follow-up neurovascular imaging: 21 aneurysms had complete occlusion, 4 had residual neck filling, and 2 had residual dome filling. Periprocedural complications (<30 days) occurred in 3 patients (10.7%), including 1 case of device failure resulting in stroke. Outcomes were good (modified Rankin Scale score 0 to 2) in 27 patients (96.4%) and fair (modified Rankin Scale 3) in 1. PED can be utilized in the treatment of distal anterior circulation aneurysms with difficult anatomy for conventional surgical or endovascular techniques. Larger-scale studies with long-term follow-up are needed to further elucidate the durability of PED treatment and its effect on perforator-rich vascular segments. ACA, anterior cerebral arteryAcomA, anterior communicating arteryDSA, digital subtraction angiographyMCA, middle cerebral arterymRS, modified Rankin scalePED, Pipeline embolization device.

FT02. Incomplete Circle of Willis Is Associated With a Higher Incidence of Neurologic Events During Carotid Eversion Endarterectomy Without Shunting

A complete circle of Willis (CoW) is considered an important collateral network to maintain blood flow during cross-clamping in carotid endarterectomy (CEA). The aim of this study was to evaluate the impact of an incomplete CoW with isolated middle cerebral artery (i-MCA) on immediate neurologic events (INE) after CEA. We reviewed the clinical data and outcomes of 545 patients (332 males; mean age, 69 ± 8 years) who underwent CEA under general anesthesia between 2013 and 2015. All patients had preoperative computed tomography angiography (CTA) of the extra- and intracranial cerebral circulation. Indications were asymptomatic (52%) and symptomatic (48%) carotid artery disease. Patients who had CEA with shunt and those with inadequate intracranial imaging to assess CoW were excluded. CTAs were reviewed independently by two vascular radiologists who were blinded for treatment outcomes. Imaging assessment included the vertebral and carotid circulation, and each segment of the CoW, which was classified as normal, hypoplastic (diameter ˂1 mm), or absent. The ipsilateral MCA was considered isolated if there was absence of anterior and posterior communicating branches from the contralateral carotid or posterior circulations. INE was defined as any transient ischemic attack (TIA) and stroke diagnosed immediately after the procedure. INE occurred in 19 patients (3.5%) after the procedure, 12 (2.2%) had TIA and seven (1.3%) had stroke. Isolated MCA was found in 30 patients (5.5%). Six of 30 patients (20%) had INE (4 TIAs and 2 strokes; odds ratio [OR], 9.65; 95% confidence interval [CI], 3.38-27.6; P ˂ .001). Only one patient had INE with contralateral ICA occlusion (OR, 0.92; 95% CI, 0.12-7.11; P = 1.0), but this patient also had i-MCA. An isolated MCA carries nearly a 10-fold higher risk of INEs after CEA with cross-clamping without shunt protection. In these patients, routine shunting is recommended to prevent INEs.

Posterior Reversible Encephalopathy Syndrome: Clinical Differences in Patients with Exclusive Involvement of Posterior Circulation Compared to Anterior or Global Involvement

Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiologic syndrome not yet fully understood and characterized by transient neurologic symptoms in addition to typical radiological findings. There are only a few articles that describe the clinical differences between patients with PRES that involve carotid and vertebrobasilar circulations. Our study aims to further evaluate the differences between predominantly anterior and posterior circulation PRES. We review 54 patients who had received the diagnosis of PRES from 2009 to 2015. The patients were divided into 2 groups: (1) exclusively in posterior zones; and (2) anterior plus posterior zones or exclusively anterior zones. Several clinical characteristics were evaluated, including the following: age, sex, previous diseases, the neurologic manifestations, the highest blood pressure in the first 48 hours of presentation, highest creatinine level during symptoms, and the neuroimaging alterations in brain magnetic resonance imaging. Mean age at diagnosis was 28.5 years old (9 men and 45 women) and mean systolic blood pressure among patients with lesions only in posterior zones was 162.1 mmHg compared to 179.2 mmHg in the anterior circulation. The most common symptoms in the 2 groups were headache and visual disturbances. PRES may have several radiological features. A higher blood pressure seems to be 1 of the factors responsible for developing widespread PRES, with involvement of carotid vascular territory. This clinical-radiological difference probably occurs because of the larger number of autonomic receptors in the carotid artery in comparison to the vertebral-basilar system.

Computational fluid dynamics analysis of flow reduction induced by flow-diverting stents in intracranial aneurysms: a patient-unspecific hemodynamics change perspective

Background and purposeFlow-diverter stents (FDSs) have been used effectively to treat large neck and complex saccular aneurysms on the anterior carotid circulation. Intra-aneurysmal flow reduction induces progressive aneurysm thrombosis in...

Abstract 31: Incidence of Recurrence in Posterior Circulation Childhood Arterial Ischemic Stroke: A Prospective Cohort

Introduction: Childhood arterial ischemic stroke (CAIS) affects 1.6 per 100,000/year and recurs in up to 20% at 5 years. Arteriopathies are common, predict recurrence, and affect the carotid (anterior) and vertebrobasilar (posterior) circulations differently. Differences in recurrence between anterior and posterior circulation CAIS have not been evaluated. Hypothesis: Recurrence is higher for stroke involving the posterior circulation (PCAIS) than anterior circulation (ACAIS). Methods: We analyzed 107 CAIS cases (61 isolated ACAIS, 46 isolated PCAIS) from a single-center prospective consecutive cohort from 1/1/06-1/1/15, with median age 7.7 years (IQR=3.1-13.6) and 70% male. Incidence of recurrent stroke was assessed with Kaplan-Meier survival estimates. Cox proportional hazards models compared recurrence risk between PCAIS and ACAIS. Results: Median follow-up was 20.9 months (IQR 8.7-40.4). Recurrent stroke occurred in 9/46 PCAIS cases (19.6%; 8 males; 2 with multiple recurrences) and in 2/61 ACAIS cases (3.3%; 2 males). All PCAIS cases with recurrence were receiving antithrombotic therapy (aspirin or anticoagulant). Stroke risk factors in PCAIS with recurrence were: cervical dissection (4), sickle cell anemia (1), cardiac disease (2), multiple factors (2), thrombophilia (1), and unknown (1). For ACAIS, recurrence-free survival at 1 month, was 100%, and at 1 and 5 years was 96% (95% CI 85-99%). For PCAIS, recurrence-free survival at 1 month, 1 year, and 5 years was 88% (95% CI 75-95%), 81% (95% CI 66-90%), and 74% (95% CI 52-87%) [Figure]. The hazard ratio for recurrence in PCAIS compared to ACAIS was 6.4 (95% CI 1.4-29.8, p=0.017) in univariable analysis and 6.8 (95% CI 1.3-35.7, p=0.023) adjusting for sex, cardiac cause, and dissection. Conclusions: At 5 years, 26% of children with PCAIS in our cohort had recurrent stroke compared to only 4% of children with ACAIS. Children with PCAIS may benefit from closer monitoring and additional prevention strategies.

The fetal brain sparing response to hypoxia: physiological mechanisms.

How the fetus withstands an environment of reduced oxygenation during life in the womb has been a vibrant area of research since this field was introduced by Joseph Barcroft, a century ago. Studies spanning five decades have since used the chronically instrumented fetal sheep preparation to investigate the fetal compensatory responses to hypoxia. This defence is contingent on the fetal cardiovascular system, which in late gestation adopts strategies to decrease oxygen consumption and redistribute the cardiac output away from peripheral vascular beds and towards essential circulations, such as those perfusing the brain. The introduction of simultaneous measurement of blood flow in the fetal carotid and femoral circulations by ultrasonic transducers has permitted investigation of the dynamics of the fetal brain sparing response for the first time. Now we know that major components of fetal brain sparing during acute hypoxia are triggered exclusively by a carotid chemoreflex and that they are modified by endocrine agents and the recently discovered vascular oxidant tone. The latter is determined by the interaction between nitric oxide and reactive oxygen species. The fetal brain sparing response matures as the fetus approaches term, in association with the prepartum increase in fetal plasma cortisol, and treatment of the preterm fetus with clinically relevant doses of synthetic steroids mimics this maturation. Despite intense interest into how the fetal brain sparing response may be affected by adverse intrauterine conditions, this area of research has been comparatively scant, but it is likely to take centre stage in the near future.

ANALYSIS OF THE SURGICAL OUTCOMES OF COMBINED ATHERSCLEROTIC LESIONS OF CAROTID AND CORONARY ARTERIES

The article provides surgical treatment outcomes of combined atherosclerotic lesions of carotid and coronary arteries in 143 patients who underwent different surgical treatment tactics. The major criteria for the choice of surgical treatment stages in patient Group 1 were degree of carotid and coronary circulation lesion and severity of clinical manifestations of CAD and chronic cerebrovascular insufficiency. Surgical treatment for patient Group 2 was identified taking into account the study data of functional reserve of myocardial and cerebral perfusion. In patient Group 3 the tactics of simultaneous surgical treatment was based only on the presence of combined, hemodynamically significant atherosclerotic lesion of carotid and coronary arteries. The outcomes showed that functional evaluation of myocardial and cerebral perfusion reserve allows differentiation of high risk patients with combined atherosclerotic lesion of carotid and coronary circulation and thus contributes to the choice of the best possible surgical treatment tactics. Simultaneous surgeries are reasonable for the patients with lowered reserve of both coronary and cerebral circulation. Moreover, the risk of cerebral and cardiac postoperative complications in such patients is not higher than that after staged surgical treatment.

SPECIFICS OF SUBFRACTIONAL SPECTRUM OF APOLIPOPROTEIN B RELATED LIPOPROTEINES IN CAROTID OR CORONARY ATHEROSCLEROSIS PATIENTS

Apolipoprotein (apo)B-containing lipoproteines of low density are heterogeneous by their nature, and differ by their lipid and protein contents, charge, particle size and functional activity. High blood level of small dense particles of low-density lipoproteines (LDL) is related to higher risk of coronary heart disease 3-5 times irrelevant to cholesterol level they contain. Aim. To evaluate and describe the specifics of subfraction spectrum of apo-Bcontaining lipoproteines in patients with lesions in carotid and/or coronary circulation. Material and methods . Totally, 310 patients included (62,5±9,3 year old), underwent duplex scanning of carotid arteries and coronary arteriography (M/F 203/107). Sub fraction spectrum of lipoproteines was assessed with electrophoresis on 3% polyacrylamide gel (Lipoprint system, Quantimetrix Lipoprint LDL System, USA). The level of severity of coronary atherosclerosis lesion was assessed with the Gensini Score (GS). Results. Evaluation of subfractional spread of lipoproteines according to the results of duplex scan showed that in the group of patients with intima-media thickness (IMT) >0,9 mm part of intermediate density lipoproteides (IDL) C is higher (11,0±3,6 vs 9,1±2,8%, р=0,002), and the part of low density lipoproteides (LDL) 1 is lower (16,7±4,1 vs 18,1±3,7%, р=0,047) comparing to the patients with normal IMT. Assessment of the spread of LDL subfractions according to the number of atherosclerotic plaques (AP) and/or lesion of carotid arteries showed that among the patients with ≥3 AP and/or involved carotid arteries for >45%, the part of LDL C decreased (9,9±3,2 vs 11,4±3,7%, р=0,003), but there is increase of intermediate density lipoproteides A (IDL A) (9,3±2,6 vs 8,4±2,5%, р=0,013) and large particles of IDL 1 (17,8±4,0 vs 16,2±4,0%, р=0,005) and comparing to those having 0, n=242). Coronary patients were selected to subgroups with minimal or mild (GS 0 part of very low density lipoproteines (VLDL) (21,0±4,1 vs 19,3±4,1%, р=0,004) and IDL (11,4±3,4 vs 10,5±3,3%, р=0,047) were higher, and part of IDL A (8,4±2,5 vs 9,4±2,6%, р=0,006) and large particles IDL 1 (16,8±4,2 vs 18,2±4,2%, р=0,013) lower than group GS =0. In the group GS ≥35 the part of IDL C was significantly higher comparing to those from GS <35 (11,8±3,7 vs 10,8±3,0%, р=0,008). According to multifactor regression, the risk of coronary atherosclerosis is related to higher part of VLDL (OR =1,1, 95% CI 1,0-1,2, р=0,039), small dense particles of LDL 3-6 (OR =1,3, 95% CI 1,0-1,6, р=0,049), and higher part of LDL 2 is associated with the risk of coronary atherosclerosis by 10% GS score (OR =0,9, 95% CI 0,8-1,0, р=0,014). Conclusion. Combination of carotid and coronary arteries is related to the changes of subfractional lipoproteides spectrum (lower part of IDL A and large particles of LDL 1 and higher part of VLDL), characteristic for isolated lesion of coronary arteries regardless its prominence, which probably might be regarded as additional markers of atherogenity of lipid profile in earlier stage carotid and any coronary atherosclerosis.

Early-onset bilateral cerebral arteriopathies: Cohort study of phenotype and disease course.

To describe characteristics of young children with arterial ischemic stroke (AIS) and bilateral cerebral arteriopathies. Retrospective review of clinical features, course, and outcome. Neuroimaging was analyzed for infarct pattern, cerebrovascular diagnosis (anatomic/Childhood Arterial Ischemic Stroke Standardized Classification and Diagnostic Evaluation [CASCADE] criteria), and disease progression. In the 31 children (median age, 18 months), presentations included acute hemiparesis (n=23) and focal seizures (n=12). Seven had systemic arterial disease; 13 had cardiac abnormalities. Twenty had recurrent AIS or transient ischemic attack (after median of 3 months); 16 had >1 recurrence. Median modified Rankin Scale score was 3, with motor impairments in 20, cognitive impairments in 11, and seizures in 7. At presentation, 17 had old and acute infarcts. Twenty-five had high signal in white matter. A total of 13/23 reimaged patients accrued further infarcts over a median of 39 months. Arteriopathy involved the carotid circulation bilaterally in all; 6 had posterior circulation and 11 had extracranial involvement. Arteriopathy distribution was symmetric in 24/31. CASCADE categories were 3A in 19, 3B in 5, 3C in 5, and 7 in 2. After a median of 35 months, 14 had had progression of arteriopathy. Patients categorized as CASCADE 3A (moyamoya) had significantly shorter time to recurrence than other groups. Young children with bilateral cerebral arteriopathies (particularly meeting criteria for CASCADE 3A) have a malignant course, with frequent recurrent events, progressive disease, and poor outcomes. Current classifications are limited in characterizing disease in many cases. Symmetric involvement suggests these arteriopathies may be developmentally determined, while systemic involvement suggests potential genetic etiology.