Nondisabling Stroke Research Articles

Multiplug paravalvular leak closure using Amplatzer Vascular Plugs III: A prospective registry.

Transcatheter paravalvular leak closure (TPVLC) offers a viable alternative to reoperation but optimal technical strategy is still to be defined. We present a prospective TPVLC registry in which safety and efficacy of multi-plug, single-stage approach were assessed. Patients with heart failure (HF) symptoms caused by PVL were qualified for TPVLC by Heart Team. Ante- or retrograde access was employed for mitral while retrograde only for aortic PVLs. Two to 4 AVP 3 devices were simultaneously implanted into each PVL. Endpoints were defined according to VARC-2. From 64 referred patients 49, with either mechanical valves (n = 30) or stented bioprostheses, were eligible for TPVLC. PVL location was mitral (n = 29) or aortic (n = 20). In aortic group acute procedural success (APS) ratio was 100% and no MACCEs occurred. In mitral group, first-attempt TPVLC was successful in 22 cases (4/4 in transapical and 18/25 in transseptal access). Second-attempt transapical procedure followed transseptal failure in 5 patients. Mitral TPVLC ultimately proved efficient in 89.7% with 76.5% APS. Cumulatively, TPVLC was accomplished in 46 subjects (93.9%) with 78% APS. When successful, it led to a significant decrease of NT-proBNP concentration and HF symptoms regression. Periprocedural safety endpoints were met in three patients and included non-disabling stroke, and two access site-related complications. In device failure group two patients died (end-stage HF) and two others were rehospitalized. TPVLC with simultaneous deployment of multiple AVP III occluders is feasible with high device success rate and no significant periprocedural complications. The clinical benefits of reduction of HF symptoms and hemolysis are evident after 30 days and persist up to 1 year without recurrence of PVL.

Comparing Patient and Physician Risk Tolerance for Bleeding Events Associated with Anticoagulants in Atrial Fibrillation—evidence from the United States and Japan

ObjectivesAtrial fibrillation (AF) is a factor in the development of thrombi that can lead to ischemic strokes. Anticoagulants are crucial in preventing strokes among patients with AF but are associated with bleeding risks. Recent studies have shown that despite anticoagulants’ efficacy in stroke prevention, many patients with AF receive subtherapeutic levels of anticoagulation because of concerns about bleeding. Of particular interest is to quantify the perceived relative importance of treatment-related benefits and risks and how these perceptions vary between patients and physicians in different countries. MethodsPatients’ and physicians’ preferences were elicited using a discrete-choice experiment. We evaluated disagreements in preferences for the benefits and risks of anticoagulants. ResultsA total of 186 patients with AF and 107 physicians in the United States completed the survey. In Japan, 152 patients and 164 physicians completed the same survey. Japanese patients were relatively less averse than US patients to bleeding risks. Physicians in both countries did not distinguish between nondisabling and disabling strokes. US patients were less tolerant than physicians of nonmajor clinically relevant bleeding risk when this risk was a consequence of preventing nondisabling strokes. Japanese patients were generally more tolerant than physicians of bleeding risks when the risks were consequences of preventing both nondisabling and disabling strokes. ConclusionsOverall, preferences for anticoagulant benefits and risks were not statistically different between patients and physicians in the United States, nor were there differences in preferences for different stroke risks between physicians in the United States and Japan; however, preferences were different between patients and physicians in Japan.

Urgent carotid endarterectomy in carotid artery stenosis with a pedunculated thrombus: a case report

Intraluminal thrombus in the context of carotid artery stenosis is rarely encountered. The prevention of major disabling stroke is one of the foremost goals of the urgent treatment of carotid lesions with an intraluminal thrombus. Urgent carotid endarterectomy following non-disabling stroke or crescendo transient ischemic attacks is a safe and feasible procedure with favorable outcomes. Endovascular therapy may not be suitable in selected cases. Carotid artery stenosis with a pedunculated thrombus, as in the present case, has a higher risk of embolization than other intraluminal thrombi. Herein, we describe a case with recurrent episodes of amaurosis fugax, who underwent urgent carotid surgery due to a pedunculated thrombus.

Abstract T MP26: Progression Of Asymptomatic Carotid Stenosis: Incidence Of Symptoms And Predictive Factors

Background: Given the uncertainty regarding clinical applicability of early treatment trials and lack of data on long-term disease progression, we evaluated the progression of stenosis and development of symptoms on patients with asymptomatic carotid artery stenosis (ACAS) treated with contemporary medical therapy over a prolonged follow up. Methods: Retrospective review of bilateral carotid arteries from consecutive patients diagnosed with moderate or severe ACAS, at our institution between 2000 and 2001. Patient vascular risk factors and treatments, cerebrovascular imaging, ipsilateral symptoms, and revascularization were recorded. Progression of stenosis was defined by change category of stenosis. Factors associated with symptomatic carotid disease were sought using univariate and multivariate logistic regression analysis. Results: We identified 214 patients (58.8% men; median age 70 years) and collected data on 349 vessels. Severe stenosis (>70%) upon diagnosis was present in 92(26.4%) vessels. All patients were on antithrombotics, 97% on antihypertensives, and 95% on statins. Median length of follow up was 13 years (range 5-14) and the mean number of time points with follow-up imaging was 8.1±3.9. Progression of stenosis was observed in 237(67.9%) vessels. 72(20.6%) patients developed symptomatic carotid stenosis (TIA in 14.4%, non-disabling stroke in 4%, and disabling stroke in 2.2%). Median time to appearance of first symptom was 6 years (range 1-13). Revascularization procedures were performed in 118(33.8%) vessels, including 73(61.9%) vessels which had become symptomatic. On multivariate analysis, baseline stenosis (OR 1.65, 95%CI 1.12-2.44), intracranial stenosis > 50% (OR 2.87, 95%CI 1.46-5.62), plaque ulceration (OR 3.41, 95%CI 1.34-8.69), silent infarction (OR 4.25, 95%CI 2.30-7.83), and previous history of TIA/stroke (OR 2.73, 95%CI 1.14-6.54) were associated with development of TIA/stroke ipsilateral to the carotid stenosis. Conclusions: There is a substantial rate of progression of stenosis in patients with asymptomatic carotid atherosclerosis over time despite adequate medical therapy. Over long-term follow up, one in five patients with ACAS developed ipsilateral TIA/stroke.

Abstract W MP35: The Re-examining Acute Eligibility for Thrombolysis Task Force Criteria for Defining Rapidly Improving Stroke Symptoms: A Pilot Prospective Study of tPA Treatment Decisions

Background: Rapidly Improving Stroke Symptoms (RISS) is a controversial exclusion criterion for tPA for acute ischemic stroke (AIS). Prior studies suggest 4-44% of AIS patients eligible are not given tPA solely because of RISS and their outcome is not invariably benign. In 2013 The Re-examining Acute Eligibility for Thrombolysis (TREAT) Task Force published new criteria for defining RISS. Objectives: To estimate frequency and outcome of RISS based on TREAT criteria in a prospective cohort of consecutive AIS patients. Methods: Serial NIH Stroke Scales (NIHSS) for AIS patients admitted within 4.5 hrs of symptom onset were performed every 20 (±5) minutes until a treatment decision (tPA vs no tPA) was made, independent of the study. Improvement was calculated as the difference between baseline NIHSS (bNIHSS) and treatment decision NIHSS (tdNIHSS). Per TREAT criteria, RISS was defined as improvement to a non-disabling mild stroke and none of the following deficits present: complete hemianopsia; severe aphasia; visual or sensory extinction; any weakness limiting sustained effort against gravity; any total NIHSS >5; any remaining deficit considered potentially disabling by the patient and the treater. We compared frequency and outcomes of TREAT-based RISS with the most commonly used RISS definition [≥4 point improvement (4PI) on NIHSS]. Good outcome was defined as modified Rankin Scale of 0-1 at 3 months. Results: Fifty AIS were enrolled: mean age 65 yrs; median bNIHSS=5 (IQR 2,11); median tdNIHSS=5 (IQR 2,9); tPA was given in 23 (46%). Five/50 (10%) were RISS according to TREAT criteria, all 5 had good outcome at 90 days without tPA. Five/50 (10%) were RISS according to 4PI, and only 2/5 (40%) had good outcome while 1/5 (20%) died. Conclusions: This is the first preliminary, prospective estimate of RISS frequency and outcome according to TREAT criteria vs. a commonly used RISS definition. Our pilot data suggest the TREAT RISS frequency is in the lower end of prior retrospective estimates and, as a more restrictive definition, may better predict good outcome of RISS in future, larger studies.

Impairment of attention in post-stroke fatigue and depression

To study the relationship between impairment of attention and development of pathological fatigue and depression after non-disabling stroke. Thirty patients were examined. Attention was assessed by the Attention Network Test (ANT). Pathological fatigue and depression were assessed by the Fatigue assessment scale and depression subscale of the Hospital Anxiety and Depression Scale, respectively. The association between the severity of depression and fatigue after stroke and reduction of mean reaction time in ANT was found. A decrease in the reaction time may be one of the factors reducing working ability in patients with post-stroke fatigue and depression even in the absence of severe neurological deficit. This has to be taken into account when planning rehabilitation.

Extracorporeal membrane oxygenation for very high-risk transcatheter aortic valve implantation

Introduction: Transcatheter aortic valve implantation (TAVI) can cause profound haemodynamic perturbation in the peri-operative period. Veno-arterial extracorporeal membrane oxygenation (ECMO) can be used to provide cardiorespiratory support during this time, either prophylactically or emergently. Methods: 100 TAVI procedures were performed between 2009 and 2013 in our institution. ECMO was used in 11 patients, including 8 prophylactic and 3 rescue cases. Rescue ECMO was required for ventricular fibrillation after valvuloplasty, and aortic annulus rupture. The criteria for prophylactic ECMO included heart failure requiring stabilisation pre-TAVI, haemodynamic instability with balloon aortic valvuloplasty performed to improve heart function pre-TAVI, moderate or severe left and/or right ventricular failure, or borderline haemodynamics at procedure. Differences in preoperative characteristics and postoperative outcomes between ECMO and non-ECMO TAVI patients were compared, and significant results were further assessed controlling for EuroSCORE. Results: Compared to TAVI patients who did not require ECMO, ECMO patients had significantly higher mean EuroSCORE (51 vs. 30%, p<.05). All-cause mortality occurred in nil prophylactic ECMO patients, one rescue ECMO patient, and two non-ECMO patients. The difference in mortality between ECMO and non-ECMO patients was not significantly different (9 vs. 2%; p>.05). Other non-significant outcomes (p<.05) included peri-procedural and spontaneous myocardial infarction (0 vs. 2% and 0 vs. 0%, respectively); disabling and non-disabling stroke (0 vs. 0% and 0 vs. 2%, respectively); transient ischaemic attack (0 vs. 0%); life-threatening, major and minor bleeding (12 vs. 3%, 0 vs. 12% and 38 vs. 13%, respectively); and major and minor vascular complications (12 vs. 5% and 0 vs. 13%, respectively). ECMO patients were more likely to develop acute renal failure than non-ECMO patients (36 vs. 8%, p<.05), which was most likely due to haemodynamic collapse and end-organ dysfunction in patients that required emergent ECMO rescue. Discussion: ECMO, in both prophylactic and rescue settings, is effective at providing cardiorespiratory support in very-high risk TAVI patients, and may have contributed to the low mortality in this series. Instituting prophylactic ECMO in an elective, controlled setting may help avoid consequences of intraoperative complications such as systemic hypoperfusion and acute renal failure, compared to emergent ECMO with rapid setup and cannulation. Limitations of this study include small patient sample size and observational nature. Future studies performed in a prospective, randomised fashion are required to evaluate the use of prophylactic ECMO, and to determine the ideal selection criteria.

Digital subtraction angiography (DSA) is superior to duplex ultrasound in diagnosis of extracranial carotid stenosis - a comparative study

Digital subtraction angiography (DSA) is the gold standard investigation to assess the extracranial stenosis of carotid vessels. But this is an invasive diagnostic tool. So it is still a controversial issue whether duplex ultrasound is an alternative to DSA for measurement of stenosis of carotid vessels. This prospective crossectional observational study was conducted in the department of Neurology, BSMMU, Dhaka from May 2012 to April 2013 to assess the diagnostic accuracy of duplex ultrasound and its potential to replace DSA before performing carotid endarterectomy (CEA) and carotid stenting. Total of 38 patients, 33 patients of nondisabling ischaemic stroke and 5 patients with history of TIAs whose extracranial carotid stenosis was &gt;50% on duplex ultrasound were selected for DSA. DSA was done on these vessels and stenosis was measured using NASCET criteria. Results of USD and DSA were compared to determine the sensitivity, specificity and accuracy of duplex ultrasound (USD). At 70% stenosis of right internal carotid artery and left internal carotid artery the sensitivity, specificity and accuracy were 93.8%, 63.7%, 89.5% and 93.3%, 75%, 89.5% respectively. This level of diagnostic efficiency of USD is less than that of DSA of carotid arteries. It was found in this study that, USD underestimates or overestimates the degree of carotid stenosis. DSA was safe and effective in determining stenosis in this study &amp; there was no 67 complication. So before taking any decision for carotid endarterectomy or carotid artery stenting, digital subtraction angiography of carotid vessels should be done. DOI: http://dx.doi.org/10.3329/bmj.v43i2.21385 Bangladesh Med J. 2014 May; 43 (2): 67-71

Computed tomography identifies patients at high risk for stroke after transient ischemic attack/nondisabling stroke: prospective, multicenter cohort study.

Ischemia on computed tomography (CT) is associated with subsequent stroke after transient ischemic attack. This study assessed CT findings of acute ischemia, chronic ischemia, or microangiopathy for predicting subsequent stroke after transient ischemic attack. This prospective cohort study enrolled patients with transient ischemic attack or nondisabling stroke that had CT scanning within 24 hours. Primary outcome was subsequent stroke within 90 days. Secondary outcomes were stroke at ≤2 or >2 days. CT findings were classified as ischemia present or absent and acute or chronic or microangiopathy. Analysis used Fisher exact test and multivariate logistic regression. A total of 2028 patients were included; 814 had ischemic changes on CT. Subsequent stroke rate was 3.4% at 90 days and 1.5% at ≤2 days. Stroke risk was greater if baseline CT showed acute ischemia alone (10.6%; P=0.002), acute+chronic ischemia (17.4%; P=0.007), acute ischemia+microangiopathy (17.6%; P=0.019), or acute+chronic ischemia+microangiopathy (25.0%; P=0.029). Logistic regression found acute ischemia alone (odds ratio [OR], 2.61; 95% confidence interval [CI[, 1.22-5.57), acute+chronic ischemia (OR, 5.35; 95% CI, 1.71-16.70), acute ischemia+microangiopathy (OR, 4.90; 95% CI, 1.33-18.07), or acute+chronic ischemia+microangiopathy (OR, 8.04; 95% CI, 1.52-42.63) was associated with a greater risk at 90 days, whereas acute+chronic ischemia (OR, 10.78; 95% CI, 2.93-36.68), acute ischemia+microangiopathy (OR, 8.90; 95% CI, 1.90-41.60), and acute+chronic ischemia+microangiopathy (OR, 23.66; 95% CI, 4.34-129.03) had greater risk at ≤2 days. Only acute ischemia (OR, 2.70; 95% CI, 1.01-7.18; P=0.047) was associated with a greater risk at >2 days. In patients with transient ischemic attack/nondisabling stroke, CT evidence of acute ischemia alone or acute ischemia with chronic ischemia or microangiopathy was associated with increased subsequent stroke risk within 90 days.

A randomized controlled trial to assess the psychosocial effects of early exercise engagement in patients diagnosed with transient ischaemic attack and mild, non-disabling stroke

Objective: To examine the effect of an early exercise and education programme on psychosocial health of transient ischaemic attack (TIA) and mild, non-disabling stroke patients. Design: Randomized, parallel-group, clinical trial. Setting: Hospital and academic institution. Participants: A total of 55 newly diagnosed transient ischaemic attack/mild stroke patients (Mean[SD]; 69[11]y). Intervention: Participants were randomized to either an eight-week, twice weekly, 90-minute exercise and education programme (experimental group) or to a usual care control group. Main measures: Psychosocial measures (SF-36, Hospital Anxiety and Depression Scale, Profile of Mood States, International Physical Activity Questionnaire, Stroke Awareness Questionnaire) were assessed at baseline and eight-week and 12-month follow-up. Results: The experimental group demonstrated improvements in the Physical Component Score (Mean[SD]; 44.1[11.7] to 47.4[11.3]%), Vitality (46.5[12.4] to 54.2[14.2]%), Physical Functioning (45.6[10.7] to 51.9[14.7]%), Role Physical (38.7[10.8] to 43.1[13.6]%) and Global Health (49.1[10.3] to 54.4[13.6]%) from the SF-36, at the eight-week follow-up assessment (P < 0.05). There were no further changes in these measures between the eight-week and 12-month follow-up assessment (P > 0.05). The experimental group demonstrated a greater awareness of the signs and symptoms associated with stroke (P < 0.05). There were no differences in the Mental Component Score (SF-36), the Hospital Anxiety and Depression Scale or the International Physical Activity Questionnaire between treatment groups (P > 0.05). Conclusion: Early engagement in an exercise and education programme may improve physical health perceptions in transient ischaemic attack/mild stroke patients. However, secondary prevention exercise and education programmes warrant further research with regards to their effects on perceptions of mental health in this population group.

Long-term outcomes after stenting versus endarterectomy for treatment of symptomatic carotid stenosis: the International Carotid Stenting Study (ICSS) randomised trial

SummaryBackgroundStenting is an alternative to endarterectomy for treatment of carotid artery stenosis, but long-term efficacy is uncertain. We report long-term data from the randomised International Carotid Stenting Study comparison of these treatments.MethodsPatients with symptomatic carotid stenosis were randomly assigned 1:1 to open treatment with stenting or endarterectomy at 50 centres worldwide. Randomisation was computer generated centrally and allocated by telephone call or fax. Major outcomes were assessed by an independent endpoint committee unaware of treatment assignment. The primary endpoint was fatal or disabling stroke in any territory after randomisation to the end of follow-up. Analysis was by intention to treat ([ITT] all patients) and per protocol from 31 days after treatment (all patients in whom assigned treatment was completed). Functional ability was rated with the modified Rankin scale. This study is registered, number ISRCTN25337470.Findings1713 patients were assigned to stenting (n=855) or endarterectomy (n=858) and followed up for a median of 4·2 years (IQR 3·0–5·2, maximum 10·0). Three patients withdrew immediately and, therefore, the ITT population comprised 1710 patients. The number of fatal or disabling strokes (52 vs 49) and cumulative 5-year risk did not differ significantly between the stenting and endarterectomy groups (6·4% vs 6·5%; hazard ratio [HR] 1·06, 95% CI 0·72–1·57, p=0·77). Any stroke was more frequent in the stenting group than in the endarterectomy group (119 vs 72 events; ITT population, 5-year cumulative risk 15·2% vs 9·4%, HR 1·71, 95% CI 1·28–2·30, p<0·001; per-protocol population, 5-year cumulative risk 8·9% vs 5·8%, 1·53, 1·02–2·31, p=0·04), but were mainly non-disabling strokes. The distribution of modified Rankin scale scores at 1 year, 5 years, or final follow-up did not differ significantly between treatment groups.InterpretationLong-term functional outcome and risk of fatal or disabling stroke are similar for stenting and endarterectomy for symptomatic carotid stenosis.FundingMedical Research Council, Stroke Association, Sanofi-Synthélabo, European Union.

Elevated platelet-derived growth factor AB/BB is associated with a lower risk of recurrent vascular events in stroke patients.

Platelet-derived growth factor (PDGF)-AB and BB have been shown to possess angiogenic properties in vivo, and decreased levels have been linked to plaque instability in atherosclerosis. Little work has been done to determine if PDGF is associated with outcomes after stroke, in particular cognitive outcomes. Therefore, in this sudy, we investigated the association between PDGFand both vascular and cognitive outcomes in a cohort of patients with recent nondisabling ischemic stroke. Three hundred nine patients recruited within six-months of a transient ischemic attack or nondisabling ischemic stroke [modified Rankin Scale (mRS) ≤ 3] were followed for up to five-years. Cox proportional-hazard regression analyses were performed to investigate the association of PDGF levels with the risk of death, recurrent vascular events, dependency, and incident dementia, while logistic regression analyses were performed to investigate the association of PDGF levels with the risk of significant cognitive decline. Significant cognitive decline was defined as : (a) a decline of cognitive status from no cognitive impairment or mild cognitive impairment with no dementia to moderate cognitive impairment with no dementia or (b) conversion to dementia. Patients (mean age 60 years) were mostly male (64%) and of Chinese ethnicity (85%) and had posterior circulation or lacunar infarcts (73%). In univariate analysis, PDGF was significantly associated with a lower risk of recurrent vascular events [hazard ratio (HR) 0·61; 95% confidence interval (CI) 0·44-0·84]. In multivariate analysis adjusting for treatment, PDGF was independently associated with a lower risk of recurrent vascular events (HR 0·62; 95% CI 0·46-0·85). PDGF levels were not associated with the risk of the other outcomes of interest. Higher levels of PDGF-AB/BB were independently associated with a lower risk of recurrent vascular events in a cohort of convalescent nondisabled stroke patients. Our findings suggest that PDGF-AB/BB may potentially serve as a prognostic marker for outcomes pos- stroke and, if this result is validated in larger samples, a potential therapeutic target.

Stroke subtype, vascular risk factors, and total MRI brain small-vessel disease burden.

Objectives:In this cross-sectional study, we tested the construct validity of a “total SVD score,” which combines individual MRI features of small-vessel disease (SVD) in one measure, by testing associations with vascular risk factors and stroke subtype.Methods:We analyzed data from patients with lacunar or nondisabling cortical stroke from 2 prospective stroke studies. Brain MRI was rated for the presence of lacunes, white matter hyperintensities, cerebral microbleeds, and perivascular spaces independently. The presence of each SVD feature was summed in an ordinal “SVD score” (range 0–4). We tested associations with vascular risk factors, stroke subtype, and cerebral atrophy using ordinal regression analysis.Results:In 461 patients, multivariable analysis found that age (odds ratio [OR] 1.10, 95% confidence interval [CI] 1.08–1.12), male sex (OR 1.58, 95% CI 1.10–2.29), hypertension (OR 1.50, 95% CI 1.02–2.20), smoking (OR 2.81, 95% CI 1.59–3.63), and lacunar stroke subtype (OR 2.45, 95% CI 1.70–3.54) were significantly and independently associated with the total SVD score. The score was not associated with cerebral atrophy.Conclusions:The total SVD score may provide a more complete estimate of the full impact of SVD on the brain, in a simple and pragmatic way. It could have potential for patient or risk stratification or early efficacy assessment in clinical trials of interventions to prevent SVD progression and may (after further testing) have a useful role in clinical practice.

Impact of Living and Socioeconomic Characteristics on Cardiovascular Risk in Ischemic Stroke Patients

We aimed to stratify the risk of vascular event recurrence in patients with cerebral infarction according to living and socioeconomic characteristics and geographic region. The Outcomes in Patients with TIA and Cerebrovascular Disease (OPTIC) study is an international prospective study of patients aged 45 years or older who required secondary prevention of stroke [following either an acute transient ischemic attack, minor ischemic strokes, or recent (less than six-months previous), stable, first-ever, nondisabling ischemic stroke]. A total 3635 patients from 245 centers in 17 countries in four regions (Latin America, Middle East, North Africa, South Africa) were enrolled between 2007 and 2008. The outcome measure was the two-year rate of a composite of major vascular events (vascular death, myocardial infarction and stroke). During the two-year follow-up period, 516 patients experienced at least one major cardiovascular event, resulting in an event rate of 15·6% (95% confidence interval 14·4-16·9%). Event rates varied across geographical region (P < 0·001), ranging from 13·0% in Latin America to 20·7% in North Africa. Unemployment status, living in a rural area, not living in fully serviced accommodation (i.e., house or apartment with its own electricity, toilet and water supply), no health insurance coverage, and low educational level (less than two-years of schooling) were predictors of major vascular events. Major vascular event rates steeply increased with the number of low-quality living/socioeconomic conditions (from 13·4% to 47·9%, adjusted P value for trend <0·001). Vascular risk in stroke patients in low- and middle-income countries varies not only with the number of arterial beds involved but also with socioeconomic variables.

Relative importance of benefits and risks associated with antithrombotic therapies for acute coronary syndrome: patient and physician perspectives

Background:In acute coronary syndrome (ACS), antithrombotic therapies prevent thrombotic events, but also increase bleeding risk. Knowledge is limited about how patients and physicians balance these benefits and risks.Objective:To quantify US patient and physician preferences for outcomes associated with antithrombotic therapies in ACS.Methods:Two independent web-based surveys were conducted using best–worst scaling in board-certified cardiologists and adult patients hospitalized within the last 5 years due to heart attack and who used aspirin or prescription antithrombotic therapies. Participants selected best and worst of three possible outcomes across a series of questions. Outcomes included death, various levels of stroke, myocardial infarction (MI), and bleeding. Data were analyzed using a maximum difference model employing random-parameters logit. Relative importance of each outcome was estimated relative to death.Findings:Patients (n = 206) and physicians (n = 273) who met face validity requirements, viewed death and nonfatal major disabling stroke as nearly equivalent and most important outcomes to avoid. Relative to death and disabling stroke, physicians considered nondisabling stroke, all nonfatal bleeding, and mild MI all as least important to avoid, while patients considered all bleeds, except major bleeding requiring transfusion, as least important to avoid. Physicians considered severe MI equivalent to 0.92 (0.02 SE) deaths. Patients (∼0.35 [0.04] deaths) and physicians (∼0.64 [0.05] deaths) had different views for nonfatal moderate stroke. Patients viewed nonfatal major bleeding requiring transfusion ∼0.13 (0.02) deaths, and nonfatal heart attack ∼0.09 (0.02) deaths.Conclusion:US patients and physicians agree on the relative importance of avoiding death, disabling stroke and bleeding without transfusions. Differing perspectives on bleeding requiring transfusions, MI, and moderately disabling stroke suggest that patients and physicians may have different benefit–risk preferences. Transparent discussion between physicians and patients in ACS treatment shared decision-making seems warranted, although limitations of survey methodology and cultural differences compared with US participants should be considered.

Safety of early endarterectomy in patients with symptomatic carotid artery stenosis: an international multicenter study.

Although the latest recommendations suggest that carotid endarterectomy (CEA) should be performed in symptomatic carotid artery stenosis (sCAS) patients within 2 weeks of the index event, only a minority of patients undergo surgery within the recommended time-frame. The aim of this international multicenter study was to prospectively evaluate the safety of early CEA in patients with sCAS in everyday clinical practice settings. Consecutive patients with non-disabling acute ischaemic stroke (AIS) or transient ischaemic attack (TIA) due to sCAS (≥ 70%) underwent early (≤ 14 days) CEA at five tertiary-care stroke centers during a 2-year period. Primary outcome events included stroke, myocardial infarction (MI) or death occurring during the 30-day follow-up period and were defined according to the International Carotid Stenting Study criteria. A total of 165 patients with sCAS [mean age 69 ± 10 years; 69% men; 70% AIS; 6% crescendo TIA; 8% with contralateral internal carotid artery (ICA) occlusion] underwent early CEA (median elapsed time from symptom onset 8 days). Urgent CEA (≤ 2 days) was performed in 20 cases (12%). The primary outcomes of stroke and MI were 4.8% [95% confidence interval (CI) 1.5%-8.1%] and 0.6% (95% CI 0%-1.8%). The combined outcome event of non-fatal stroke, non-fatal MI or death was 5.5% (95% CI 2.0%-9.0%). Crescendo TIA, contralateral ICA occlusion and urgent CEA were not associated (P > 0.2) with a higher 30-day stroke rate. Our findings indicate that the risk of early CEA in consecutive unselected patients with non-disabling AIS or TIA due to sCAS is acceptable when the procedure is performed within 2 weeks (or even within 2 days) from symptom onset.

Unprotected carotid artery stenting in symptomatic elderly patients: a single-center experience

Background and purposeSurgery is known to have fewer adverse events in patients aged >75 years with carotid stenosis, but some are not candidates due to comorbidity. Stenting using protection devices...

Vascular risk factors, large-artery atheroma, and brain white matter hyperintensities.

Objective:To determine the magnitude of potentially causal relationships among vascular risk factors (VRFs), large-artery atheromatous disease (LAD), and cerebral white matter hyperintensities (WMH) in 2 prospective cohorts.Methods:We assessed VRFs (history and measured variables), LAD (in carotid, coronary, and leg arteries), and WMH (on structural MRI, visual scores and volume) in: (a) community-dwelling older subjects of the Lothian Birth Cohort 1936, and (b) patients with recent nondisabling stroke. We analyzed correlations, developed structural equation models, and performed mediation analysis to test interrelationships among VRFs, LAD, and WMH.Results:In subjects of the Lothian Birth Cohort 1936 (n = 881, mean age 72.5 years [SD ±0.7 years], 49% with hypertension, 33% with moderate/severe WMH), VRFs explained 70% of the LAD variance but only 1.4% to 2% of WMH variance, of which hypertension explained the most. In stroke patients (n = 257, mean age 74 years [SD ±11.6 years], 61% hypertensive, 43% moderate/severe WMH), VRFs explained only 0.1% of WMH variance. There was no direct association between LAD and WMH in either sample. The results were the same for all WMH measures used.Conclusions:The small effect of VRFs and LAD on WMH suggests that WMH have a large “nonvascular,” nonatheromatous etiology. VRF modification, although important, may be limited in preventing WMH and their stroke and dementia consequences. Investigation of, and interventions against, other suspected small-vessel disease mechanisms should be addressed.

Giant aneurysm of the abdominal aorta

A 79-year-old man with a history of smoking, hypertension, chronic pulmonary disease, and nondisabling stroke was admitted to the emergency department due to loss of consciousness and diffuse abdominal pain. At admission, the patient was vigil but hypotensive (90/60 mm Hg) and tachycardic (107 bpm). Physical examination revealed a tender, pulsatile mass occupying the entire abdomen (A). His hemoglobin level was 6.5 g/dL. Computed tomographic angiography revealed a giant infrarenal aortic aneurysm with a maximum transverse diameter of 256 mm (B and C). A small layer of blood was visible in the left retroperitoneal space. Considerable displacement of the mesentery and left kidney was evident after postprocessing reconstruction (D). Anatomic constraints, which included a severely angulated, wide conical infrarenal neck, tortuous iliac arteries, and wide aortic lumen, precluded endovascular repair. The patient underwent emergency open repair through a transperitoneal midline approach. Temporary supraceliac aortic clamping was necessary for proximal control. After evacuation of the aneurysm sac content, an inlay aortoeaortic Dacron graft reconstruction was performed (E). Despite prolonged hospitalization due to respiratory complications and transient renal deterioration, the patient was discharged home after 39 days. The rupture risk of abdominal aortic aneurysms is intimately associated with the maximum diameter. However, other factors are known to influence the risk of rupture, and individual variability is considerable. Current recommendations advise repair for aneurysms >5.5 cm in diameter. For aneurysms >6 cm, the annual rupture risk exceeds 14%. Therefore, it is rare to encounter very large aneurysms (>10 cm); most would have previously ruptured or undergone repair. Unidentified protective factors for rupture possibly may allow aneurysms to occasionally grow insidiously to extreme dimensions. Although open repair may present significant technical difficulties, endovascular repair with current endovascular devices is frequently impossible due to anatomic limitations. To our knowledge, this case represents the largest abdominal aortic aneurysm ever reported.

Abstract 57: Safety of Early and Urgent Carotid Endarterectomy (CEA) in Symptomatic Carotid Artery Stenosis (sCAS): An International, Multicenter Study

Background&amp;Purpose: Although the latest AHA recommendations suggest that CEA should be performed within two weeks of the index event in patients with sCAS, only a minority of patients undergoes surgery within the recommended time-frame because of a perceived higher incidence of complications. The aim of this international, multicenter study was to prospectively evaluate the safety of early CEA in patients with SCAS in “everyday clinical practice” settings. Subjects&amp;Methods: Consecutive patients with non-disabling (modified Rankin Scale grade&lt;3) acute ischemic stroke (AIS) or TIA due to sCAS (≥70%) underwent early (≤14 days from symptom onset) CEA at five tertiary care stroke centers during a two-year period. Primary outcome events included any stroke, myocardial infarction (MI) or death occurring during the 30-day follow-up period and were defined according to the International Carotid Stenting Study criteria. Secondary outcome events included cranial nerve palsy (CNP) and neck hematoma (NH). Results: A total of 165 patients with sCAS (mean age 69±10years; 69% men; 70% acute ischemic stroke, 30% TIA; crescendo TIA 6%; contralateral internal carotid artery occlusion 8%) underwent early CEA during the study period. The median elapsed time from symptom onset to carotid revascularization was 8 days (range 1-14). A total of 20 (12%) patients underwent urgent CEA (within two days from symptom onset). The primary outcomes of stroke and MI were 4.8% (95%CI: 1.5%-8.1%) and 0.6% (0%-1.8%) respectively. All strokes included cerebral infarctions that occurred in the territory of the symptomatic internal carotid artery (ICA). The combined outcome event of non-fatal stroke, non-fatal MI or death was 5.5% (2.0%-9.0%). The rates of CNP and NH were 6.7% and 3.6%. Crescendo TIA, contralateral ICA occlusion and urgent CEA were not associated (p&gt;0.2) with a higher rate of peri-procedural events. Conclusions: Our findings indicate that the risk of early CEA in consecutive unselected patients with non-disabling stroke or TIA due to sCAS is acceptable when the procedure is performed within 2 weeks as well as within 2 days from symptom onset.