Incidence Of Cerebral Ischemic Events Research Articles

Clinical characteristics and efficacy analysis of various treatments for spontaneous carotid artery dissection

Objective: To investigate the clinical features of spontaneous carotid artery dissection (SCAD) and the efficacy of different treatment methods. Methods: The clinical data of 164 patients with SCAD who were treated at the First Affiliated Hospital of Zhengzhou University from June 2018 to January 2023 were retrospectively analyzed. There were 127 males and 37 females, with a mean age of (49.5±11.1) years. They were divided into conservative treatment group (n=100) and surgical treatment group (n=64) according to whether they received surgical treatment. Patients were followed at 3, 6, and 12 months after discharge and annually thereafter through outpatient or inpatient visits. The incidence of cerebral ischemic events, cerebral hemorrhage events, and mortality rates during hospitalization and follow-up periods were analyzed in the two patient groups. To examine correlates of revascularization in SCAD, multifactorial logistic regression analysis was used. Results: Of the 164 patients, 18 patients had bilateral SCAD and a total of 182 carotid arteries were included in the study. Ischemic stroke (85 cases, 51.8%) and transient ischemic attack (31 cases, 18.9%) were the main clinical manifestations in SCAD patients. Hypertension (81 cases, 49.4%) and hyperlipidemia (39 cases, 23.8%) were the main comorbidities in SCAD patients. During hospitalization, 100 patients in the conservative treatment group received medication in 113 carotid arteries, no new cerebral ischemic events or symptomatic intracranial hemorrhage events occurred, and no death occurred. A total of 69 carotid arteries were surgically treated in 64 patients in the surgical treatment group. The success rate was 97.1% (67/69). In the surgical treatment group, the proportion of carotid stenosis degree≥90% was 47.8% (33/69), the proportion of type Ⅱ SCAD was 60.9% (42/69), and the proportion discharged from the hospital to receive antiplatelet therapy was 92.8% (64/69), which were higher than those in the conservative treatment group, which were 25.7% (29/113), 45.1% (51/113), and 73.5% (83/113), respectively (all P<0.05). The follow-up time [M(Q1, Q3)] in the conservative treatment group was 24 (13, 34) months, with an 8% (9/113) rate of ischemic events and a 7.1% (8/113) rate of readmission; in the surgical treatment group, the follow-up time was 24 (11, 38) months, and there were no new ischemic events or deaths. The results of multifactorial logistic regression analysis showed that the degree of true luminal stenosis<90% (OR=2.738, 95%CI: 1.067-7.026, P=0.036) and type Ⅰ dissections (OR=2.656, 95%CI: 1.189-5.935, P=0.017) were the correlates of complete revascularization. Conclusions: Ischemic stroke and transient ischemic attack are the main clinical manifestations in patients with SCAD. Pharmacological antithrombotic therapy remains the method of choice, and endovascular treatment after failure of conservative therapy reduces the risk of recurrent long-term cerebral ischemic events and the re-admission rate of patients.

The association between patent foramen ovale and unexplained syncope in pediatric patients

BackgroundPatent foramen ovale (PFO) is associated with transient ischemia attack (TIA) or stroke, paradoxical embolism, and migraines. PFO closure decreases the recurrent incidence of cerebral ischemic events and reduces the incidence of syncope in adults. However, whether PFO is associated with syncope in pediatric patients has not been investigated.Methods1001 pediatric patients (aged 4 to 17 years, mean age 10.31 ± 2.61 years, 519 males) who complained of unexplained syncope, palpitation, headache, dizziness and chest pain and were hospitalized in the Syncope Ward, The Second Xiangya Hospital, Central South University between January 2013 and April 2022 were recruited. Children with definite etiology of syncope, neurological, cardiogenic, psychological and other system diseases were excluded. PFO was measured by transthoracic echocardiography and right-heart contrast echocardiography was performed to identify the presence of right-to-left shunting. The demographic data and medical records were retrospectively reviewed and analyzed.Results276 cases were included in the simple syncope group, 379 cases in the headache/dizziness group, 265 cases in the chest pain group, and 81 cases in the palpitation group. The incidence of PFO between the four groups was insignificant (4.71%, 4.74%, 4.15%, 6.17%, respectively, P = 0.903). Multivariate Logistic regression demonstrated that PFO is not associated with the increased risk of syncope (P = 0.081).ConclusionPFO may not increase the risk of syncope in pediatric patients. Further study may include a large and multicenter sample to investigate the association between PFO and unexplained syncope.

The mid-term results of the Carotid Asymptomatic Stenosis (CARAS) observational study

IntroductionCarotid endarterectomy (CEA) in patients with asymptomatic carotid stenosis (ACAS) remains a subject of debate. Current recommendations are based on randomized trials conducted over 20 years ago and improvements in medical therapies may have reduced the risk of cerebral ischemic events (CIE). This study presents a mid-term analysis of results from an ongoing prospective observational study of ACAS patients to assess their CIE risk in a real-world setting. MethodsThis is a prospective observational cohort study of patients with ACAS >60 % (NASCET criteria) identified in a single duplex ultrasonography (DUS) vascular laboratory (trial registered: NCT04825080). Patients were not considered for CEA due to their short life expectancy (<3 year) or absence of signs of plaque vulnerability (ulceration, ipoechogenic core). Patient enrollment started in January 2019 and ended in March 2020 with a targeted sample size of 300 patients.A 5-year follow-up was scheduled. Clinical characteristics, risk factors, and medical therapies were documented, and, when necessary, the best medical therapy (BMT), involving antiplatelet agents, blood pressure control, and statins, was recommended during clinical visits. The primary endpoint was to asses CIEs (including strokes, transient ischemic attacks, amaurosis-fugax) ipsilateral to ACAS along with plaque progression rate and patients survival. Follow-up involved annual clinical visit and carotid DUS examination, complemented by telephone interviews at six-month intervals. ResultsThe study included 307 patients, with an average age of 80 ± 7 years, of whom 55 % were male. Contralateral stenosis exceeding 60 % was present in 61 (20 %) patients. Seventy-seven percent of patients were on BMT. At a mean follow-up of 41±9 months, 7 ispilateral strokes and 9 TIAs occurred, resulting in 14 CIEs (2 patients experienced both TIA and stroke). According to Kaplan–Meier analysis, the 4-year CIE rate was 6±2 %, with an annual CIE rate of 1.5 %. Fifty-eight (19 %) patients had a stenosis progression which was associated with a higher 4-year estimated CIE rate compared to patients with stable plaque (10.3 % vs 3.2 %, P=.01). Similarly, a contralateral carotid stenosis >60 % was associated with a higher 4-year estimated CIE rate: 11.7 % vs 2.9 %, P=.002. These factors were independently associated with high risk for CIE at the multivariate COX analysis: Hazard Ratio (HR): 3.2; 95 % Confidence Interval: 1.1-9.2 and HR: 3.6; 95 % CI: 1.2-10.5. ConclusionThe mid-term results of this prospective study suggest that the incidence of CIE in ACAS patients should not be underestimated, with plaque progression and contralateral stenosis serving as primary predictors of CIEs.

Outcomes After Transcatheter Aortic Valve Replacement in Bicuspid Versus Tricuspid Anatomy: A Systematic Review and Meta-Analysis.

The aim of this study was to compare the feasibility, safety, and clinical outcomes of transcatheter aortic valve replacement (TAVR) in bicuspid aortic valve (BAV) versus tricuspid aortic valve (TAV) stenosis. At present, limited observational data exist supporting TAVR in the context of bicuspid anatomy. Primary endpoints were 1-year survival and device success. Secondary endpoints included moderate to severe paravalvular leak (PVL) and a composite endpoint of periprocedural complications; incidence rates of individual procedural endpoints were also explored individually. In the main analysis, 17 studies and 181,433 patients undergoing TAVR were included, of whom 6,669 (0.27%) had BAV. A secondary analysis of 7,071 matched subjects with similar baseline characteristics was also performed. Device success and 1-year survival rates were similar between subjects with BAV and those with TAV (97% vs 94% [P=0.55] and 91.3% vs 90.8% [P=0.22], respectively). In patients with BAV, a trend toward a higher risk for periprocedural complications was observed in our main analysis (risk ratio [RR]: 1.12; 95% CI: 0.99-1.27; P=0.07) but not in the matched population secondary analysis (RR: 1.00; 95%CI: 0.81-1.24; P=0.99). The risk for moderate to severe PVL was higher in subjects with BAV (RR: 1.42; 95%CI: 1.29-1.58; P< 0.0001) as well as the incidence of cerebral ischemic events (2.4% vs 1.6%; P=0.015) and of annular rupture (0.3% vs 0.02%; P=0.014) in matched subjects. TAVR is a feasible option among selected patients with BAV anatomy, but the higher rates of moderate to severe PVL, annular rupture, and cerebral ischemic events observed in the BAV group warrant caution and further evidence.

Clinical experience of carotid endarterectomy for the treatment of carotid stenosis

Objective To investigate the clinical outcomes and prognosis of carotid endarterectomy (CEA) for moderate to severe carotid stenosis. Method The clinical data of 78 patients with moderate or severe carotid stenosis treated with CEA from March 2015 to December 2017 at Department of Neurosurgery, the First Affiliated Hospital of Zhengzhou University (18 cases) and Department of Neurosurgery, General Hospital of Tianjin Medical University (60 cases) were retrospectively analyzed. There were 72 cases of symptomatic stenosis, 6 cases of asymptomatic stenosis. Among them, there were 66 cases of unilateral stenosis and 12 cases of bilateral stenosis. All patients were treated with standard CEA. There were 72 cases of unilateral CEA and 6 cases of bilateral CEA. A total of 84 CEA operations were performed. Results All operations were performed successfully. The clamping duration was 18.0 to 52.0 minutes, with an average of 28.0±4.2 minutes. During perioperative period, there were 3 new cases of cerebral infarction, including 1 case of massive cerebral infarction and 1 case of transient ischemic attack. The incidence of cerebral ischemic events was 4.8% (4/84). No intracranial hemorrhage or death occurred after operation. All patients were followed up for 6.0 to 38.0 months, with an average of 18.0±3.2 months. There were 4 (4.8%) cases of restenosis (stenosis degree ≥50%) after operation, including 2 cases of cerebral infarction, 1 case of transient ischemic attack and 1 asymptomatic case. Conclusions CEA is an effective treatment for moderate to severe carotid stenosis. Standardized perioperative management and operative procedures could help to reduce postoperative complications and achieve good clinical results. Key words: Endarterectomy, cartoid; Carotid stenosis; Atherosclerosis; Complication

Seven years' follow-up of comparative study between stenting and medication for treatment of symptomatic vertebrobasilar artery stenosis.

Objective Endovascular stent-assistant angioplasty (ESAA) is a valid treatment for symptomatic vertebrobasilar artery stenosis (SVAS), but the long-term effect and the improvement of condition compared with medication treatment are unknown. This study investigated the long-term efficacy of ESAA in patients with moderate and severe SVAS, and compared the efficacy with medication treatment. Materials and methods We conducted a retrospective analysis of clinical data of 43 patients with moderate and severe SVAS hospitalized in our department. According to different treatment methods they were divided into 29 cases in an ESAA group and 14 cases in a medication treatment group. During the follow-up period, the degree of vascular stenosis, vascular blood flow velocity, restenosis rate, recovery of neurological function and the incidence of cerebral ischemic events in the two groups were analyzed. Results The average clinical follow-up period was 89.4 ± 10.2 months. Before treatment, the stenosis rate and average blood flow velocity of the two groups were not statistically significant ( p > 0.05). During the follow-up period, both were significantly lower than the medication treatment group ( p < 0.01). In the ESAA group, three cases of stent stenosis, and three cases in the medication treatment group were completely occluded. The total ischemic events in ESAA group were three cases, compared with nine cases in the medication treatment group; the difference was statistically significant ( p < 0.05). Conclusion ESAA has a long-term effect in the treatment of symptomatic moderate and severe vertebrobasilar artery stenosis. It is superior to medication therapy in preventing posterior circulation ischemia (PCI), but a larger sample size is still needed to confirm the study.

Application of beach chair position and lateral decubitus position in shoulder arthroscopy

The clinical application of arthroscopic minimally invasive treatment of shoulder joint disease technology has become a routine, and it has been widely carried out around the world. Compared with the traditional open surgery, it only needs to establish a few channels in the shoulder and then the diagnosis and treatment of the structure under the acromion and glenoid joint internal lesions can be completed through the arthroscopic technique under direct vision, of course, including local collection of pathological specimens. Shoulder arthroscopic surgery has the advantages of simple operation technique, small economic burden of patients, small tissue trauma, quick recovery and high accuracy of disease diagnosis. At present, there are two main options for shoulder arthroscopy: the beach chair position (BCP) and the lateral decubitus position (LDP). The choice of surgical position for surgeons is closely related to the intraoperative operation, the risk of complications, the effi-cacy of surgery, and the cost of setting the posture. Shoulder arthroscopy of these two positions have their own advantages and disadvantages: in the BCP, the surgeon gets a better anatomical operation experience, if necessary, can be converted into open surgery at any time. Without continuous traction, upper limb nerve and vascular damage caused by traction can be avoid. But the incidence of cerebral ischemic events in patients may increase in the BCP. There is also possibility of the nerve damage of the pillow small nerve, great auricular nerve, lateral femoral cutaneous nerve and other nerves. In theory the risk of air embo-lism in the patients will increase in the BCP, and the cost of setting the position is also higher than the LDP. While in the LDP due to the patient's forearm continuous traction, the surgeon can get a more extensive operating space, and the occur-rence of cerebral ischemic events is very rare. In the treatment of anterior shoulder instability after shoulder arthroscopic sur-gery, there is a lower recurrence rate in the LDP. The cost of setting the position is also significantly lower than the BCP. Of course, the disadvantages of the LDP is also obvious. In the LDP, the brachial plexus and other nerves or vascular injury may increase due to the continuous traction of the forearm. Meanwhile sustained traction in the LDP is also a risk factor for throm-bosis, and so on. Therefore, there is still a debate about the optimal location of the shoulder arthroscopy. Many clinicians choose shoulder arthroscopic position based on their own experience and habits.

Incidence of cerebral ischemic events after discontinuation of clopidogrel in patients with intracranial aneurysms treated with stent-assisted techniques

The optimal antiplatelet medication protocol for prevention of thrombotic complications after stent-assisted coil embolization of cerebral aneurysms is unclear. Early cessation of antiplatelet agents may be associated with an increased risk of cerebral ischemic events. In this study, the authors assess the incidence of stroke or transient ischemic attack (TIA) following discontinuation of a 6-week course of clopidogrel in patients with cerebral aneurysms treated with stent-assisted techniques. A retrospective review was conducted in all patients with cerebral aneurysms undergoing stent-assisted coil embolization or stent-in-stent flow diversion at the University of Iowa during a 24-month period. The antiplatelet protocol was 81 mg aspirin and 75 mg clopidogrel daily for 6 weeks, followed by 325 mg aspirin daily indefinitely. The incidence of stroke or TIA was determined by a retrospective review of medical records generated during a 3-month period following discontinuation of clopidogrel. A total of 154 patients underwent aneurysm treatment with stent techniques during this interval. Documentation of neurological follow-up 3 months after discontinuation of a 6-week clopidogrel treatment was available in 121 (78.6%) of 154 patients. Of these 121 patients, 114 were treated with stent-assisted coil embolization and 7 with stent-in-stent flow diversion. Six patients (5%) suffered an ischemic event after cessation of clopidogrel, with 2 events occurring within the first 2 weeks. Specifically, the rate of ischemic events was 5 (4.3%) of 114 in the "stent-coil" treatment group and 1 (14.3%) of 7 in the stent-in-stent group. Treatment had been performed in the setting of a subarachnoid hemorrhage in 1 patient. Atypical aneurysm features and technical factors predisposing to thrombotic events were found in all but one of these patients. Similarly, cardiovascular risk factors were present in 5 of the 6 patients in whom ischemic events developed after clopidogrel discontinuation. Clopidogrel discontinuation is associated with a 5% risk of ischemic events in patients treated with stent techniques. Any stroke related to clopidogrel discontinuation is avoidable, and longer treatment is therefore clearly necessary. Patients with cardiovascular risk factors, high-risk aneurysm features, and those undergoing stent-in-stent flow diversion might benefit the most from longer clopidogrel therapy.

Abstract 3464: Incidence of Cerebral Ischemia After Discontinuation Of Clopidogrel (Plavix) In Patients With Cerebral Aneurysms Treated Using Stent-Assisted Technique

Background: The optimal antiplatelet medication protocol for prevention of thrombotic complications after stent-assisted coil embolization of cerebral aneurysms is unknown. Premature cessation of antiplatelet medication has been associated with increased risk of thrombosis. The current analysis is undertaken to assess the incidence of stroke or transient ischemic attack after discontinuation of 6 weeks of prescribed clopidogrel (Plavix) in patients with cerebral aneurysms treated by stent-assisted technique. Method: 275 patients with cerebral aneurysms treated at the University of Iowa Hospitals and Clinics by a single surgeon (DH) during a period of 24 months were retrospectively analyzed for aneurysms treated by stent-assisted coiling or stent-in-stent flow diversion and who also received follow-up at our center. Our antiplatelet protocol was aspirin 81 mg PO and plavix 75 mg PO daily for 6 weeks, followed by aspirin 325 mg PO daily indefinitely. Patients were assessed for incidence of stroke or transient ischemic attack as diagnosed by a neurologist or neurosurgeon by reviewing their medical record during the period of three months following discontinuation of plavix. Results: 154/275 (56%) patients underwent stent-assisted coil embolization during this interval. Documentation of neurologic follow-up after discontinuation of six-weeks of palvix treatment was available in 121/154 (78.6%) patients. Seven patients suffered an ischemic event after cessation of plavix (5.7%) with stroke in 6 patients (5.0%) and transient ischemic attack in 1 patient (0.8%). These events developed over a wide range of intervals from time of plavix discontinuation (1-12 weeks), with only one event within 2 weeks. Conclusion: The three-month incidence of cerebral ischemic events in patients treated with stent-assisted technique is low following cessation of six-week treatment of plavix. Events within two weeks of discontinuation were rare, suggesting etiologies other than stent thrombosis may have been operative in our patients.

Perioperative stress response to carotid endarterectomy: The impact of anesthetic modality

Objective Surgery for extracranial carotid artery disease has been challenged by carotid angioplasty stenting because the latter is less invasive and avoids surgical trauma. In fact, the magnitude of the perioperative stress response evoked by carotid endarterectomy (CEA) has never been evaluated. Our aim was to determine the degree of surgical trauma caused by CEA and to define differences related to the use of locoregional or general anesthesia. Methods We prospectively studied 113 consecutive CEAs performed on 109 patients admitted at a community institutional center. Patients were stratified for demographics and risk factors and operated on under locoregional (LA) or general anesthesia (GA) depending on both the surgeon preference and patient's compliance. Selective carotid shunting was performed for patients who manifested neurologic deficits under LA or had stump pressure values ≤30 mm Hg under GA. Markers of the stress response, including cortisol, adrenocorticotropic hormone, prolactin, and C-reactive protein, were measured intraoperatively, before and after carotid artery cross-clamping (CACC), and postoperatively up to the third day after surgery. Hemodynamic variability was assessed during surgery and for 24 hours postoperatively. Operative times were also measured. Surgeons were considered as independent variables for stress response. Statistics were run by means of nonparametric tests and univariate and multivariate analysis with a linear regression model. Results CEA was performed under GA in 63 cases (55.8%) and under LA in 50 (44.2%). The two groups were comparable in terms of demographics and risk factors. Intraoperatively, cortisol and adrenocorticotropic hormone levels were significantly higher in the LA group (both P < .001). CACC increased the intraoperative cortisol levels in both the GA ( P = .019) and the LA groups ( P = .006). However, in patients who underwent carotid shunting, this effect was abolished (GA group, P = .779; LA group, P = 1.0). During the early postoperative period there was no difference between the two groups. On postoperative day 1 the stress response was abolished in both groups. Prolactin levels increased intraoperatively in both the LA and GA groups and returned within preoperative values on postoperative day 1. Prolactin levels were higher in the GA group ( P = .003 intraoperatively and P < .001 postoperatively). C-reactive protein significantly increased in both GA and LA groups on postoperative days 1 and 2 and started to decrease on day 3 with no differences between the two groups at any time. Hemodynamic variability and considered risk factors including individual surgeon were not significant variables. Gender-related differences were found only in prolactin secretion. The length of surgery had an impact for procedures that lasted >120 minutes. Three patients experienced an intraoperative neurologic event and had higher post-CACC cortisol values as compared to asymptomatic patients. Conclusions Intraoperative surgical stress was higher under LA and was blunted by carotid shunting under both LA and GA. Within 2 hours after surgery the anesthetic modality no longer had any impact on surgical trauma. The stress response to CEA, regardless of the type of anesthesia, was abolished within 24 hours. Intraoperative stress response, namely hypercortisolemia, directly correlated with subclinical and clinical cerebral hypoperfusion/ischemia during CACC. Hence, attenuation of the stress response to CEA might decrease the incidence of cerebral ischemic events.

Outcome in patients with asymptomatic neck bruits.

Five hundred asymptomatic patients with cervical bruits were followed prospectively by clinical and Doppler examination for up to four years (mean, 23.2 months) to identify the variables predicting outcome. Thirty-six patients had strokes or transient ischemic attacks, 51 had cardiac ischemic events, and 45 died. At one year the incidence of cerebral ischemic events (transient ischemic attacks and strokes) was 6 percent, that of cardiac ischemic events was 7 percent, and that of death was 4 percent. The overall incidence of stroke at one year was 1.7 percent (1 percent in patients without previous transient ischemic attacks), but the incidence was 5.5 percent in patients with severe carotid-artery stenosis (greater than 75 percent). Cerebral ischemic events were most frequent in patients with severe carotid-artery stenosis (P less than 0.0001), progressing carotid-artery stenosis (P less than 0.0005), or heart disease (P less than 0.0005) and in men (P less than 0.025). The degree of carotid-artery stenosis on initial presentation was a powerful predictor of neurologic sequelae. Patients with asymptomatic cervical bruits have a higher risk of a cardiac ischemic event than of a stroke. Although the risk of cerebral ischemic events is highest in patients with severe carotid-artery stenosis, in most instances even these patients do not have strokes without some warning.