78 research outputs found
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Rectifying the Misconceptions about Current Best Management of Asymptomatic Carotid Stenosis is Not about Revising History
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Additional Opportunity to Rectify Misconceptions Regarding Current Best Management of Asymptomatic Carotid Stenosis
No full textOptimizing the Definitions of Stroke, Transient Ischemic Attack, and Infarction for Research and Application in Clinical Practice
No full textBackground and purposeUntil now, stroke and transient ischemic attack (TIA) have been clinically based terms which describe the presence and duration of characteristic neurological deficits attributable to intrinsic disorders of particular arteries supplying the brain, retina, or (sometimes) the spinal cord. Further, infarction has been pathologically defined as death of neural tissue due to reduced blood supply. Recently, it has been proposed we shift to definitions of stroke and TIA determined by neuroimaging results alone and that neuroimaging findings be equated with infarction.MethodsWe examined the scientific validity and clinical implications of these proposals using the existing published literature and our own experience in research and clinical practice.ResultsWe found that the proposals to change to imaging-dominant definitions, as published, are ambiguous and inconsistent. Therefore, they cannot provide the standardization required in research or its application in clinical practice. Further, we found that the proposals are scientifically incorrect because neuroimaging findings do not always correlate with the clinical status or the presence of infarction. In addition, we found that attempts to use the proposals are disrupting research, are otherwise clinically unhelpful and do not solve the problems they were proposed to solve.ConclusionWe advise that the proposals must not be accepted. In particular, we explain why the clinical focus of the definitions of stroke and TIA should be retained with continued sub-classification of these syndromes depending neuroimaging results (with or without other information) and that infarction should remain a pathological term. We outline ways the established clinically based definitions of stroke and TIA, and use of them, may be improved to encourage better patient outcomes in the modern era
Association between spontaneous internal carotid artery dissection and perivascular adipose tissue attenuation on computed tomography angiography
No full textPublished August 2023Background: Spontaneous cervical artery dissection (sCAD) is a leading cause of ischemic stroke in young patients. Studies using high-resolution magnetic resonance imaging and positron emission tomography have suggested vessel wall inflammation to be a pathogenic factor in sCAD. Computed tomography (CT) attenuation of perivascular adipose tissue (PVAT) is an established non-invasive imaging biomarker of inflammation in coronary arteries, with higher attenuation values reflecting a greater degree of vascular inflammation. Objectives: We evaluate the CT attenuation of PVAT surrounding the internal carotid artery (PVATcarotid) with and without spontaneous dissection. Methods: Single-center prospective observational study of 56 consecutive patients with CT-verified spontaneous dissection of the internal carotid artery (ICA). Of these patients, six underwent follow-up computed tomography angiography (CTA). Twenty-two patients who underwent CTA for acute neurological symptoms but did not have dissection formed the control group. Using semi-automated research software, PVATcarotid was measured as the mean Hounsfield unit (HU) attenuation of adipose tissue within a defined volume of interest surrounding the ICA. Results: PVATcarotid was significantly higher around dissected ICA compared with non-dissected contralateral ICA in the same patients (−58.7±10.2 vs −68.9±8.1HU, p<0.0001) and ICA of patients without dissection (−58.7±10.2 vs −69.3±9.3HU, p<0.0001). After a median follow-up of 89days, there was a significant reduction in PVATcarotid around dissected ICA (−57.5±13.4 to −74.3±10.5HU, p<0.05), while no change was observed around non-dissected contralateral ICA (−71.0±4.4 to −74.1±4.1HU, p=0.19). ICA dissection was an independent predictor of PVATcarotid following multivariable adjustment for age and the presence of ICA occlusion. Conclusion: PVATcarotid is elevated in the presence of sCAD and may decrease following the acute event.Kevin Cheng, Andrew Lin, Ximena Stecher, Tomas Bernstein, Paulo Zuñiga, Enrico Mazzon, Alejandro Brunser, Violeta Diaz, Gonzalo Martinez, William Cameron, Stephen J Nicholls, Sanjay Patel, Damini Dey, Dennis TL Wong, and Paula Muñoz Venturell
Intravenous thrombolysis after reversion of acenocoumarol anticoagulation. Report of one case
No full textWe report an 89-year-old male under oral anticoagulant therapy with a therapeutic international normalized ratio, presenting at the emergency room with right side hemiparesis and aphasia. Neuroimaging was compatible with an acute middle cerebral artery ischemic stroke. Anticoagulation was reverted with the use of four factor prothrombin complex, followed by thrombolysis with alteplase, with a favorable evolution, returning to his basal functional status
Misconceptions regarding the adequacy of best medical intervention alone for asymptomatic carotid stenosis
No full textBACKGROUND: Medical intervention (risk factor identification, lifestyle coaching, and medication) for stroke prevention has improved significantly. It is likely that no more than 5.5% of persons with advanced asymptomatic carotid stenosis (ACS) will now benefit from a carotid procedure during their lifetime. However, some question the adequacy of medical intervention alone for such persons and propose using markers of high stroke risk to intervene with carotid endarterectomy (CEA) and/or carotid angioplasty/stenting (CAS). Our aim was to examine the scientific validity and implications of this proposal. METHODS: We reviewed the evidence for using medical intervention alone or with additional CEA or CAS in persons with ACS. We also reviewed the evidence regarding the validity of using commonly cited makers of high stroke risk to select such persons for CEA or CAS, including markers proposed by the European Society for Vascular Surgery in 2017. RESULTS: Randomized trials of medical intervention alone versus additional CEA showed a definite statistically significant CEA stroke prevention benefit only for selected average surgical risk men aged less than 75 to 80 years with 60% or greater stenosis using the North American Symptomatic Carotid Endarterectomy Trial criteria. However, the most recent measurements of stroke rate with medical intervention alone are overall lower than for those who had CEA in these randomized trials. Randomized trials of CEA versus CAS in persons with ACS were underpowered. However, the trend was for higher stroke and death rates with CAS. There are no randomized trial results related to comparing current optimal medical intervention with CEA or CAS. Commonly cited markers of high stroke risk in relation to ACS lack specificity, have not been assessed in conjunction with current optimal medical intervention, and have not been shown in randomized trials to identify those who benefit from a carotid procedure in addition to current optimal medical intervention. CONCLUSIONS: Medical intervention has an established role in the current routine management of persons with ACS. Stroke risk stratification studies using current optimal medical intervention alone are the highest research priority for identifying persons likely to benefit from adding a carotid procedure
The Role of TCD in the Evaluation of Acute Stroke
No full textBACKGROUND: The additional information that transcranial Doppler (TCD) can provide as part of a multimodal imaging stroke protocol in the setting of hyper acute strokes has not been evaluated.
METHODS: Consecutive patients admitted between December 2012 and January 2015 with ischemic stroke of less than 4.5 hours of onset were studied as soon as possible with a protocol consisting of noncontrast brain computed tomography, computed tomography angiography of supra-aortic vessels, diffusion-weighted magnetic resonance imaging, and TCD.
RESULTS: Eighty-six patients were included. The imaging protocol was performed 113.9 (+/- 23) minutes after the stroke symptoms appeared and by TCD after 150.2 (+/- 19) minutes. Sixty-six (76.7%) patients were treated with revascularization therapies. TCD provided additional information in 49 cases (56.9.4%, 95 CI 46.4-66.9). More than one piece of additional information was obtained in 17 patients. The most frequent additional information was collateral pathways, information related to patency of vessels, and active microembolization. Multivariate analysis demonstrated that, intracranial vessel occlusion (P < .001) and optimal sonographic windows (P <. 004) were the variables associated with additional information. In 15 patients (17.4%; 95 CI 9.4-25.5) the additional information changed the management. In 8 patients endovascular rescue was applied after the failure of intravenous thrombolysis; in 5 patients angiography was suspended and in 2 other cases aggressive neurocritical care was indicated.
CONCLUSIONS: TCD in the first 4.5 hours of acute ischemia can provide additional information to a multimodal acute ischemic stroke imaging protocol, and can induce changes in the management of a proportion of these patients
Pre-stroke adherence to a Mediterranean diet pattern is associated with lower acute ischemic stroke severity: a cross-sectional analysis of a prospective hospital-register study
No full textBackground: High adherence to a Mediterranean Diet is associated with reduced incidence and mortality of acute ischemic stroke (AIS) but may also be associated with severity. Our purpose was to investigate the association of adherence to a Mediterranean diet and severity in a prospective hospital register of AIS patients.
Methods: We included AIS patients admitted from February 2017 to July 2019. All were assessed by a neurologist with a standard stroke protocol, including NIHSS. Adherence to Mediterranean diet was prospectively measured by the 14-point Mediterranean Diet Adherence Screener (MEDAS) and defined as low (0–6 points) or high (7–14 points). Demographic and clinical characteristics were compared by group with univariate analysis. A Generalized Linear Model (GLM) was used to investigate the association of admission NIHSS as a continuous ordinal variable and an ordinal logistic regression (OLR) analysis to determine the independent association of the NIHSS quartiles with adherence to Mediterranean diet.
Results: Three hundred sixty-eight patients were included, mean age 68.3 (17.7), 158 (42.9%) females. The median NIHSS score was 3 (IQR 1–9) and the median MEDAS score was 6 (IQR 4.5–8). Patients with high MEDAS scores had significantly lower; admission NIHSS scores, sedentary lifestyle, body mass index, total and LDL cholesterol levels, but higher alcohol consumption. After adjustments, high adherence to Mediterranean diet remained independently associated with lower stroke severity both in the GLM (β coefficient = − 0.19, p = 0.01) and in the OLR model (OR for lower NIHSS quartiles 0.6 (95% CI 0.37–0.98, p = 0.04).
Conclusions: Higher pre-stroke adherence to a Mediterranean diet is independently associated with lower AIS severity
Intraventricular Bleeding and Hematoma Size as Predictors of Infection Development in Intracerebral Hemorrhage: A Prospective Cohort Study
No full textBACKGROUND:
Acute intracerebral hemorrhage (ICH) is associated with increased susceptibility to bacterial infection. The physiopathology of this phenomenon is not very clear. We conducted a prospective observational study investigating the correlation and independent predictors of infections in patients with ICH.
PATIENTS AND METHODS:
Patients admitted between April 1997 and June 2013 with ICH diagnosis were evaluated for inclusion and exclusion criteria.
RESULTS:
Two hundred twenty-two patients were included in this study. Ninety four patients (42.6%) presented with an infection during hospitalization being more common than pneumonia (30%) and urinary tract infections (14%). Intraventricular hemorrhage (IVH) (95% confidence interval [CI], 62.7% versus 39.3%; P < .001) and higher ICH score (95% CI, 2.31% versus 1.67%; P = .0014) were more common in patients who had infections. We found the following risk factors for having an infection in patients with ICH: IVH (odds ratio [OR] 2.3; 95% IC, 1.3-4.1), each point of ICH score (OR 1.3; 95% CI, 1.1-1.6), and having a hematoma volume larger than 30 cc (OR 2.0; 95% CI, 1.1-3.5). The localization of the hematoma was not found to be relevant.
CONCLUSIONS:
ICH score, size of the hematoma, and presence of IVH are independent risk factors for having an infection after ICH
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