Abstracts of Literature
Cerebrospinal Fluid Creatine Kinase-BB Isoenzyme Activity and Outcome After Subarachnoid Hemorrhage—Coplin WM (Dept of Neurology and Neurological Surgery, Wayne State Univ, 8D-UHC, 4201 St. Antoine, Detroit, MI 48201), Longstreth WT Jr, Lam AM, Chandler WL, Mayberg TS, Fine JS, Winn HR—Arch Neurol. 1999;56:1348–1352.
Background: The brain is rich in creatine kinase–BB isoenzyme activity (CK-BB), which is not normally present in cerebrospinal fluid (CSF). Results of previous studies have shown that CK-BB can be detected in the CSF of patients with aneurysmal subarachnoid hemorrhage (SAH), but whether CK-BB levels correlate with patients’ neurologic outcomes is unknown.
Objective: To evaluate the relationship between CSF CK-BB level and outcome after SAH.
Design: Prospective observational cohort.
Setting: University-affiliated tertiary care center.
Patients: Convenience sample of 30 patients seen for cerebral aneurysm clipping.
Interventions: We sampled and assayed CSF for CK isoenzymes a median of 3 days after SAH in 27 patients, and at the time of unruptured aneurysm clipping in 3 patients.
Main Outcome Measures: Without knowledge of CK results, we assigned the Glasgow Outcome Scale score early (≈1 week) and late (≈2 months) after surgery.
Results: Higher CSF CK-BB levels were associated with higher Hunt and Hess grades at hospital admission (Spearman rank correlation, ρ=0.69; P<.001), lower Glasgow Coma Scale scores at hospital admission (μ=−0.72; P<.001), and worse early outcomes on the Glasgow Outcome Scale (μ=−0.64; P<.001). For patients with a favorable early outcome (Glasgow Outcome Scale score, 3–5), all CK-BB levels were less than 40 U/L. With a cut-off value of 40 U/L, CK-BB had a sensitivity of 70% and a specificity of 100% for predicting unfavorable early outcome (Glasgow Outcome Scale score, 1–2). Having a CK-BB level greater than 40 U/L increased the chance of an unfavorable early outcome, from 33% (previous probability) to 100%, whereas a CK-BB level of 40 U/L or less decreased it to 13%. Similar findings were obtained when considering late outcomes.
Conclusion: The level of CSF CK-BB may help predict neurologic outcome after SAH.
Key Words: subarachnoid hemorrhage, stroke outcome
Efficacy and Current Limitations of Intravascular Stents for Intracranial Internal Carotid, Vertebral, and Basilar Artery Aneurysms—Lanzino G, Wakhloo AK, Fessler RD, Hartney ML, Guterman LR, Hopkins LN (Dept of Neurosurgery, 3 Gates Cr, Buffalo, NY 14209-1194)—J Neurosurg. 1999;91:538–546.
Object. Results of previous in vitro and in vivo experimental studies have suggested that placement of a porous stent within the parent artery across the aneurysm neck may hemodynamically uncouple the aneurysm from the parent vessel, leading to thrombosis of the aneurysm. For complex wide-necked aneurysms, a stent may also aid packing of the aneurysm with Guglielmi detachable coils (GDCs) by acting as a rigid scaffold that prevents coil herniation into the parent vessel. Recently, improved stent system delivery technology has allowed access to the tortuous vascular segments of the intracranial system. The authors report here on the use of intracranial stents to treat aneurysms involving different segments of the internal carotid artery (ICA), the vertebral artery (VA), and the basilar artery (BA).
Methods. Ten patients with intracranial aneurysms located at ICA segments (one petrous, two cavernous, and three paraclinoid aneurysms), the VA proximal to the posterior inferior cerebellar artery origin (one aneurysm), or the BA trunk (three aneurysms) were treated since January 1998. In eight patients, stent placement across the aneurysm neck was followed (immediately in four patients and at a separate procedure in the remaining four) by coil placement in the aneurysm, accomplished via a microcatheter through the stent mesh. In two patients, wide-necked aneurysms (one partially thrombosed BA trunk aneurysm and one paraclinoid segment aneurysm) were treated solely by stent placement: coil placement may follow later if necessary.
No permanent periprocedural complications occurred and, at follow-up examination, no patient was found to have suffered symptoms referable to aneurysm growth or thromboembolic complications. Greater than 90% aneurysm occlusion was achieved in the eight patients treated by stent and coil placement as demonstrated on immediate postprocedural angiograms. Follow-up angiographic studies performed in six patients at least 3 months later (range 3–14 months) revealed only one incident of in-stent stenosis. In the four patients originally treated solely by stent placement, no evidence of aneurysm thrombosis was observed either immediately postprocedure or on follow-up angiographic studies performed 24 hours (two patients), 48 hours, and 3 months later, respectively.
Conclusions. A new generation of flexible stents can be used to treat complex aneurysms in difficult-to-access areas such as the proximal intracranial segments of the ICA, the VA, or the BA trunk. The stent allows tight coil packing even in the presence of a wide-necked, irregularly shaped aneurysm and may provide an endoluminal matrix for endothelial growth. Although convincing experimental evidence suggests that stent placement across the aneurysm neck may by itself promote intraluminal thrombosis, the role of this phenomenon in clinical practice may be limited at present by the high porosity of currently available stents.
Key Words: aneurysm, endovascular therapy
Aneurysms in Relatives of Patients With Subarachnoid Hemorrhage: Frequency and Risk Factors—Raaymakers TWM (Dept of Neurology, H2.128, Univ Hospital Utrecht, Heidelberglaan 100, 3584 CX Utrecht, Netherlands) and the MARS Study Group—Neurology. 1999;53:982–988. Copyright © 1999 by the American Academy of Neurology.
Objective: To evaluate the frequency and identify risk factors of unruptured aneurysms in first-degree relatives of patients with sporadic subarachnoid hemorrhage (SAH). Background: First-degree relatives (parents, siblings, and children) of patients with SAH have a three to seven times increased risk of SAH. Methods: Magnetic resonance angiography (MRA) was performed in 626 first-degree relatives of a consecutive series of 193 index patients with “sporadic” SAH (participation rate, 78% of eligible relatives). The authors recorded demographic and medical data, and performed blood pressure measurements and blood tests (cholesterol, high-density lipid cholesterol, triglycerides, apoprotein A1, lipoprotein a, glucose). Results: Aneurysms were found in 25 of 626 relatives (4.0%; 95% CI, 2.6 to 5.8%), and 6 relatives had multiple aneurysms. Index patients with multiple aneurysms and a younger age had a higher risk of aneurysms in relatives. Siblings of index patients had a four times higher risk than children. In screened relatives female sex, increasing age, polycystic kidney disease, hypertension, and elevated levels of cholesterol and glucose tended to be associated with a higher risk of aneurysms. No increase in risk was conferred by smoking or alcohol use, or by a previous family history of SAH or of atherosclerosis. Conclusions: First-degree relatives of index patients with sporadic subarachnoid hemorrhage have a 4.0% chance of intracranial aneurysms. Being a sibling of the index patient is the most important risk factor. Risk factors for general atherosclerosis (hypertension, smoking, hypercholesterolemia, high levels of blood triglycerides, lipoprotein a, and apoprotein A1) and use of alcohol do not increase the risk of intracranial aneurysms significantly in these relatives.
Key Words: subarachnoid hemorrhage, genetics
Clinical and Angiographic Results of Endosaccular Coiling Treatment of Giant and Very Large Intracranial Aneurysms: A 7-Year, Single-Center Experience—Gruber A (Dept of Neurosurgery, Univ of Vienna Medical School, Waehringer Guertel 18-20, A-1090 Vienna, Austria), Killer M, Bavinzski G, Richling B—Neurosurgery. 1999;45:793–804.
OBJECTIVE: To evaluate whether the objectives of surgical treatment, i.e., prevention of aneurysmal rebleeding, relief of aneurysmal mass effect, and prevention of embolic complications, are met by endosaccular coiling treatment applied to giant and very large wide-necked aneurysms.
METHODS: Thirty patients with 31 giant or very large aneurysms were considered to show unacceptable risk/benefit ratios for open surgery and were treated using the Guglielmi detachable coil (GDC) method between 1992 and 1998.
RESULTS: With endosaccular GDC treatment, 73.3% of the population experienced excellent to good recoveries (Glasgow Outcome Scale scores of 4 or 5), with a 13.3% procedure-related morbidity rate and a 6.7% procedure-related mortality rate. Two hemorrhaging episodes occurred after GDC treatment (annual bleeding rate, 2.5%; 2 hemorrhaging episodes/79.2 patient-yr). Symptoms related to aneurysmal mass effect were improved for 45.5% of the patients presenting with signs of neural compression. Among 23 patients with 24 aneurysms who were available for angiographic follow-up assessment, complete or nearly completeé occlusion was observed for 17 aneurysms (71%; angiographic follow-up period, 24.3±19.6 mo, mean±standard deviation). A single total embolization served as definitive treatment for only 12.5% of the giant aneurysms and 31% of the very large aneurysms.
CONCLUSION: Endosaccular GDC treatment of giant and very large aneurysms was accomplished with procedure-related morbidity and mortality rates comparable to those for open surgery performed by experts. However, because coil stability was unsatisfactory, we suggest that the GDC method should currently be reserved for individuals who are considered poor candidates for open surgery.
Key Words: endovascular therapy, aneurysm
Cardiovascular, Autonomic, and Plasma Catecholamine Responses in Unilateral and Bilateral Carotid Artery Stenosis—Akinola A (Neurovascular Medicine Unit, St Mary’s Hospital, Imperial College School of Medicine, Praed St, London W2 INY, UK), Mathias CJ, Mansfield A, Thomas D, Wolfe J, Nicolaides AN, Tegos T—J Neurol Neurosurg Psychiatry. 1999;67:428–432.
Objective—To determine impairment of baroreceptor afferent activity, which may affect cardiovascular autonomic function in patients with unilateral and bilateral carotid artery stenosis. Comparison was made with normal subjects and hypertensive patients.
Methods—A series of cardiovascular autonomic function tests along with plasma noradrenaline (norepinephrine) measurements were performed in 46 patients with carotid artery stenosis (CAS); 23 had unilateral and 23 had bilateral stenosis. Comparison was made with 21 hypertensive patients (with a similar degree of raised blood pressure), and 27 normal subjects.
Results—Over a third of patients with unilateral and bilateral CAS had postural hypotension. Heart rate did not rise appropriately in CAS despite the postural fall in blood pressure. Pressor responses in CAS were preserved. Heart rate responses to respiratory stimuli were attenuated. Plasma noradrenaline concentrations rose normally during head up tilt.
Conclusion—A substantial proportion with CAS had postural hypotension and attenuated heart rate responses. This was not due to sympathetic vasoconstrictor or cardiac parasympathetic failure, thus suggesting impaired afferent baroreceptor activity, probably secondary to involvement of the carotid sinus. Cardiovascular autonomic testing and assessment of postural hypotension and factors enhancing it may be of clinical relevance in such patients, especially as the symptoms of postural hypotension overlap with those due to thromboembolism.
Key Words: carotid artery diseases, sympathetic nervous system
Open Label Tissue Plasminogen Activator for Stroke: The Oregon Experience—Egan R, Lutsep HL (Oregon Stroke Center, Oregon Health Sciences Univ, Mail Code CR-131, 3181 SW Sam Jackson Park Rd, Portland, OR 97201), Clark WM, Quinn J, Kearns K, Lockfeld A, Ireland S, Goins S, Buchholz G—J Stroke Cerebrovasc Dis. 1999;8:287–290. Copyright © 1999 by National Stroke Association.
Background: Tissue plasminogen activator (t-PA) is the first effective treatment for stroke. This study sought to explore the outcome of patients treated with t-PA in the community after approval of its use in the treatment of stroke in June, 1996. Methods: All patients with acute stroke within the 6-hospital Oregon Stroke Center network were screened for potential t-PA treatment. Baseline and 24-hour outcome assessments were performed with the use of the National Institutes of Health Stroke Scale (NIHSS) and computed tomography (CT); 3-month outcome was evaluated by using the Modified Rankin scale. Results: Thirty-three patients who met the criteria for t-PA therapy were treated within 3 hours of symptom onset. All but 2 strokes were in the anterior circulation; 48.5% were cardioembolic. The NIHSS scores at 24 hours after administration of t-PA (mean, 14.7) showed modest gains from baseline NIHSS scores (mean, 16.6). Twelve patients (36%) had minimal or no deficits at 3 months. Three patients (9%), all of whom had baseline NIHSS scores of 20 or more, had symptomatic intracranial hemorrhages, 2 of which were fatal (6%). Conclusion: This study shows the feasibility of treating acute stroke with t-PA in the community. The percentage of fully recovered patients at 3 months mirrored those in the National Institute of Neurologic Disorders and Stroke (NINDS) trial.
Key Words: stroke management, tissue plasminogen activator
Isolated Intracranial Hypertension as the Only Sign of Cerebral Venous Thrombosis—Biousse V (Neuro-ophthalmology Unit, Emory Eye Center, 1365-B Clifton Rd, Atlanta, GA 30322), Ameri A, Bousser M-G—Neurology. 1999;53:1537–1542. Copyright © 1999 by the American Academy of Neurology.
Background: Cerebral venous thrombosis (CVT) is often overlooked when intracranial hypertension (ICH) is isolated, hence mimicking idiopathic intracranial hypertension (IIH). Objective: To describe the characteristics of patients with CVT and ICH. Methods: We examined 160 consecutive patients with CVT between 1975 and 1998. They were separated into two groups according to their clinical presentation—isolated ICH and other neurologic symptoms and signs. Results: Fifty-nine patients with CVT (37%) presented with isolated ICH. Neuroimaging showed involvement of more than one sinus in 35 patients (59%). Brain CT was normal in 27 of 50 patients (54%). Lumbar puncture was performed in 44 patients and showed elevated opening pressure in 25 of 32 (78%) and abnormal CSF content in 11 (25%). Etiologies and risk factors included local causes in 7 of 59 (12%), surgery in 1, inflammatory diseases in 18 (30.5%), infection in 2, cancer in 1, postpartum state in 1, coagulopathies in 11 (19%), oral contraception in 7 (12%), and remained unknown in 11 (19%). Anticoagulants were used in 41 of 59 patients (69.5%), steroids or acetazolamide in 26 (44%), therapeutic lumbar puncture in 44 (75%), and surgical shunt in 1. Three patients had optic atrophy with severe visual loss, 1 died from carcinomatous meningitis, and 55 (93%) had complete recovery. Conclusions: Central venous thrombosis (CVT) can present with all the classical criteria for idiopathic intracranial hypertension (IIH), including normal brain CT with normal CSF content. Because the recognition of CVT has crucial prognostic and therapeutic implications, MRI, with magnetic resonance venography when necessary, should be performed in patients with isolated intracranial hypertension. The outcome of CVT is unpredictable, and management of patients with CVT should not differ whether they present with isolated raised intracranial pressure or with other neurologic symptoms and signs. Therefore, isolated raised intracranial pressure from CVT differs in management from IIH and should be classified neither as “IIH” nor “pseudotumor cerebri.”
Key Words: cerebral thrombosis, cerebral veins
Antiphosphatidyl Serine Antibodies are Independently Associated With Ischemic Stroke—Tuhrim S (Dept of Neurology, Box 1137, Mount Sinai Medical Center, One Gustave L. Levy PI, New York, NY 10029), Rand JH, Wu X, Horowitz DR, Weinberger J, Goldman ME, Godbold JH—Neurology. 1999;53:1523–1527. Copyright © 1999 by the American Academy of Neurology.
Objective: To determine whether elevated titers of antiphosphatidyl serine antibodies (aPS) are associated with an increased risk of ischemic stroke in a general stroke population. Background: aPS are members of the family of antiphospholipid antibodies that has been associated with increased stroke risk. Although aPS have been demonstrated to occur in 18% of a group of young patients with cerebrovascular symptoms, their prevalence in the general stroke population is unknown, and no controlled study to assess the strength of their association with ischemic stroke has been undertaken previously. Methods: A case-control study comparing 267 acute ischemic stroke patients and 653 community controls. Sera were obtained immediately after acute stroke in patients. Titers of IgG aPS>16 IgG phospholipid units or IgM aPS>22 IgM phospholipid units were considered positive. Odds ratios (ORs) were obtained by logistic regression, adjusting for age, gender, race/ethnicity, history of hypertension, diabetes mellitus, cardiovascular disease, and cigarette smoking. Results: The adjusted OR was 5.6 (95% confidence interval [CI] 1.8, 18.0) for IgG aPS and 2.9 (95% CI 1.6, 5.3) for IgM aPS. The adjusted OR for either an elevated IgG or IgM aPS was 3.2 (95% CI 1.8, 5.5). Conclusions: This study demonstrates that elevated IgG and IgM antiphosphatidyl serine antibodies titers are associated with increased risk of ischemic stroke. The prevalence of these antibodies is lower, but the associated stroke risk is comparable with that of anticardiolipin antibodies.
Key Words: stroke, ischemic, antibodies, antiphospholipid
Asymptomatic Carotid Arterial Disease in Young Patients Following Neck Radiation Therapy for Hodgkin Lymphoma—King LJ (Dept of Radiology, Royal Hospital Haslar, Gosport, Hampshire PO12 2AA, United Kingdom), Hasnain SN, Webb JAW, Kingston JE, Shafford EA, Lister TA, Shamash J, Reznek RH—Radiology. 1999;213:167–172.
PURPOSE: To determine the prevalence and severity of asymptomatic carotid arterial disease in young patients following neck radiation therapy for Hodgkin lymphoma and to compare the prevalence of carotid arterial disease following radiation therapy alone with that following radiation therapy and chemotherapy.
MATERIALS AND METHODS: Forty-two survivors of childhood or early adult Hodgkin lymphoma aged 18–37 years who had undergone radiation therapy more than 5 years earlier underwent carotid arterial ultrasonography. Common carotid intima-media thickness was measured; carotid vessels were assessed for intima-media abnormalities. Results were compared with those from 33 control subjects.
RESULTS: Patients had a significantly greater number of abnormal scans than did control subjects (11 [26%] vs one [3%]; P<.01). Ten patients (24%) had intima-media abnormalities that did not cause significant stenosis; one patient had diffuse bilateral intima-media thickening (mean, 1.99 mm) with greater than 70% stenosis of both common carotid arteries. Intima-media thickness was significantly greater in patients (0.51 mm) than in control subjects (0.43 mm; P<.005). The number of abnormalities in patients with radiation therapy plus chemotherapy (six [19%] of 31 patients) did not differ significantly from the number in patients with only radiation therapy (five [45%] of 11 patients; P=.12); there was no significant difference between median intima-media thicknesses (0.50 mm vs 0.51 mm, P>.2).
CONCLUSION: Asymptomatic carotid arterial disease occurs frequently in young patients following neck radiation therapy for Hodgkin lymphoma. No difference in prevalence was shown between only radiation therapy and radiation therapy plus chemotherapy.
Key Words: carotid artery diseases, radiation
Lack of Association Between Seropositivity to Chlamydia Pneumoniae and Carotid Atherosclerosis—Coles KA (Dept of Public Health, Univ of Western Australia, Nedlands, Western Australia, Australia 6009), Plant AJ, Riley TV, Smith DW, McQuillan BM, Thompson PL—Am J Cardiol. 1999;84:825–828. Copyright © 1999 by Excerpta Medica, Inc.
Since the Chlamydia pneumoniae (C. pneumoniae)-specific antibody was shown to be associated with acute myocardial infarction and chronic coronary heart disease, the role of C. pneumoniae in the etiology of cardiovascular disease has been studied by a number of groups. We investigated the association between the C. pneumoniae-specific antibody, measured by microimmunofluorescence, risk factors for cardiovascular disease, and atherosclerosis in a randomly selected urban population. Overall, immunoglobulin-G (IgG) seroprevalence to C. pneumoniae in this sample of 1,034 subjects was 58%, whereas IgA seroprevalence was 32%. There was a decline in seropositivity with age for IgG but not IgA. Men were more likely than women to be IgG (66% vs 51%, chi-square p=0.001) and IgA seropositive (36% vs 28%, chi-square p=0.005). Current smokers had higher IgA seropositivity than nonsmokers (43% vs 30%). Those patients with a family history of cerebrovascular disease were more likely to have IgG antibody than those without (75% vs 57%, chi-square p=0.007). Neither IgG nor IgA seropositivity was associated with the standard risk factors of hypertension, hyperlipidemia, or family history of ischemic heart disease, nor was seropositivity associated with carotid intima medial thickening (IMT) or atherosclerotic plaque as measured by carotid B-mode ultrasound. There was no difference between those participants who were IgG or IgA seropositive and seronegative in measurements of mean IMT, prevalence of abnormal IMT, and percentage with atherosclerotic plaque. In conclusion, although C. pneumoniae was associated with several risk factors for cardiovascular disease in a large cross-sectional population, we found no independent association between seroprevalence to C. pneumoniae and carotid atherosclerosis as measured by carotid IMT.
Key Words: atherosclerosis, infection
Westernization of Chinese Adults and Increased Subclinical Atherosclerosis—Woo KS, Chook P, Raitakari OT, McQuillan B, Feng JZ, Celermajer DS (Dept of Cardiology, Royal Prince Alfred Hospital, Missenden Rd, Camperdown NSW 2050, Sydney, Australia)—Arterioscler Thromb Vasc Biol. 1999;19:2487–2493. Copyright © 1999 American Heart Association, Inc.
Cardiovascular event rates are much lower in China compared with developed countries. “Westernization” of diet and lifestyle in the Chinese, however, may lead to an increased prevalence of atherosclerosis-related diseases. Because carotid intima-media thickness (IMT) is a marker of subclinical atherosclerosis, we examined IMT and vascular risk profile in community-based groups of rural Chinese, Westernized urban Chinese, and urban whites. Mean IMT of the common carotid artery was measured in 348 healthy adults, aged 42±13 years (range 21 to 71 years); 116 subjects from rural China, 116 urban Chinese subjects living in Hong Kong or in Australia, and 116 urban Caucasians living in Australia. These 3 groups were matched for age, sex, and cigarette smoke exposure. Urban Chinese subjects had slightly better risk factor profile (higher HDL-cholesterol and lower blood pressure) compared with rural Chinese subjects. Despite this, however, the mean IMT was lowest in rural Chinese (0.50±0.10 mm), intermediate in urban Chinese (0.56±0.12 mm), and highest in urban whites (0.64±0.13 mm) (P<0.001 for comparisons between all groups). These differences in IMT were not altered after adjustment for the major traditional cardiovascular risk factors (serum lipids, smoking, and blood pressure or for body mass index). The influence of vascular risk factors on atherosclerosis between urban versus rural Chinese subjects was studied by multivariate regression models and by comparing the steepness of regression slopes between risk factors and IMT in the subject groups. The effects of smoking, HDL-cholesterol, and triglycerides on IMT were significantly greater in the urban compared with the rural Chinese (P<0.01). These data suggest that Westernization of Chinese subjects is associated with greater susceptibility to the pro-atherogenic effects of traditional vascular risk factors, such as lipids and smoking, and with evidence of increased IMT as a marker of subclinical atherosclerosis.
Key Words: atherosclerosis, ethnic group
Fruit and Vegetable Intake in Relation to Risk of Ischemic Stroke—Joshipura KJ (Dept of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, 188 Longwood Ave, Boston, MA 02115), Ascherio A, Manson JE, Stampfer MJ, Rimm EB, Speizer FE, Hennekens CH, Spiegelman D, Willet WC—JAMA. 1999;282:1233–1239.
Context Few studies have evaluated the relationship between fruit and vegetable intake and cardiovascular disease.
Objective To examine the associations between fruit and vegetable intake and ischemic stroke.
Design, Setting, and Subjects Prospective cohort studies, including 75 596 women aged 34 to 59 years in the Nurses’ Health Study with 14 years of follow-up (1980–1994), and 38 683 men aged 40 to 75 years in the Health Professionals’ Follow-up Study with 8 years of follow-up (1986–1994). All individuals were free of cardiovascular disease, cancer, and diabetes at baseline.
Main Outcome Measure Incidence of ischemic stroke by quintile of fruit and vegetable intake.
Results A total of 366 women and 204 men had an ischemic stroke. After controlling for standard cardiovascular risk factors, persons in the highest quintile of fruit and vegetable intake (median of 5.1 servings per day among men and 5.8 servings per day among women) had a relative risk (RR) of 0.69 (95% confidence interval [CI], 0.52–0.92) compared with those in the lowest quintile. An increment of 1 serving per day of fruits or vegetables was associated with a 6% lower risk of ischemic stroke (RR, 0.94; 95% CI, 0.90–0.99; P=.01, test for trend). Cruciferous vegetables (RR, 0.68 for an increment of 1 serving per day; 95% CI, 0.49–0.94), green leafy vegetables (RR, 0.79; 95% CI, 0.62–0.99), citrus fruit including juice (RR, 0.81; 95% CI, 0.68–0.96), and citrus fruit juice (RR, 0.75; 95% CI, 0.61–0.93) contributed most to the apparent protective effect of total fruits and vegetables. Legumes or potatoes were not associated with lower ischemic stroke risk. The multivariate pooled RR for total stroke was 0.96 (95% CI, 0.93–1.00) for each increment of 2 servings per day.
Conclusions These data support a protective relationship between consumption of fruit and vegetables—particularly cruciferous and green leafy vegetables and citrus fruit and juice—and ischemic stroke risk.
Key Words: stroke, ischemic, diet
Medical Complications of Ischemic Stroke and Length of Hospital Stay: Experience in Seattle, Washington—Tirschwell DL (Dept of Neurology, Box 359775, Harborview Medical Center, 325 Ninth Ave, Seattle, WA 98104-2499), Kukull WA, Longstreth WT Jr—Stroke Cerebrovasc Dis. 1999;8:336–343. Copyright © 1999 by National Stroke Association.
Background: Medical complications of ischemic stroke can increase length of hospital stay (LOS). Stroke clinical pathways aim to reduce costs by decreasing LOS through standardization of care and avoidance of complications. Materials and Methods: Using a population-based, state-mandated, hospital discharge database, we sought to analyze the effects of common medical complications of incident ischemic stroke on LOS in Seattle, Washington from 1990 to 1994. All nonstroke medical complications listed in the discharge diagnoses with a 5% or greater frequency were entered with age and gender into linear regression models. LOS was the dependent variable. Results: The inclusion criteria was met by 4,757 hospitalizations. Congestive heart failure (9.5%), urinary tract infection (9.3%), pneumonia (7.1%), age (mean, 75), and gender (57% female) were all entered into the linear regression models. The presence of congestive heart failure was associated with an increased LOS of 24% (15% to 33%), urinary tract infection of 41% (31% to 51%), and pneumonia of 52% (40% to 65%). Multiplying the increases in LOS by the prevalence of the complications led to estimated LOS savings of 9.8% (7.1% to 12.4%). Pneumonia was associated with an odds ratio of 3.7 (2.8 to 4.8), congestive heart failure 2.0 (1.5 to 2.6), and urinary tract infection 0.6 (0.4 to 0.8) for hospital fatality. Conclusions: Each complication was associated with large and significant increases in the LOS. The potential LOS savings in these patients may be 10%, if all such complications could be avoided. Associations with increased LOS and risk of in-hospital death indicate a strong need to continue to avoid such medical complications of ischemic stroke.
Key Words: stroke, ischemic, complications
The Effect of Mild Hypothermia, Mannitol, and Insulin-Induced Hypoglycaemia on Ischaemic Infarct Volume in the Early Period After Permanent Middle Cerebral Artery Occlusion in the Rat—Kazan S (Dept of Neurosurgery, Akdeniz Univ, Faculty of Medicine, TR-07070 Antalya, Turkey), Karasoy M, Baloglu H, Tuncer R—Acta Neurochir. 1999;141:979–987.
We investigated the effect of mild hypothermia (32–34 degrees C), mannitol and insulin-induced hypoglycaemia on the ischaemic infarct volume on permanent middle cerebral artery occlusion with bilateral carotid artery ligation in rats. Temporalis muscle temperature as an indicator of brain temperature was monitored throughout the experiment in all rats, which were randomly divided into seven groups. During ischaemia, control rats received intravenous saline in a normothermic condition; treated rats had hypothermia and intravenous saline, hypothermia and mannitol, normothermia and mannitol, normothermia and insulin, normothermia, insulin and glucose, and hypothermia and insulin applied. After the experiment, the animals were killed, and brain sections were stained with haematoxylin and eosin. Images of infarct areas were determined using a camera attached to the microscope, and analysed by image analysis software. The total volume of infarcted tissue, right hemispheric volume, and the percentage of infarction were determined at the end of the image analysis investigation.
The infarct volume on the control group was found to be 128.16±6.67 mm(3). Infarct volumes in hypothermic groups were significantly smaller than those of the control group (p<0.05). There were no significant differences between infarct volumes in the hypothermic groups. However, we found that hypothermia plus mannitol have the greatest neuro-protective effect. In normothermic rats, the infarct volume decreased proportionally but not statistically (p>0.05) whether mannitol or insulin was given. Our results also demonstrate that pre-, and post-ischaemic serum glucose concentrations influence the volume of infarction. Rats that had had preischaemic serum glucose concentrations had a higher volume of infarct than the hypothermic rats (p<0.05), while rats with post ischaemic low serum glucose concentrations had a lower volume of infarct than the control rats.
Key Words: stroke, experimental, hypothermia
Adaptive Remodeling of Internal Elastic Lamina and Endothelial Lining During Flow-Induced Arterial Enlargement—Masuda H (2nd Dept of Pathology, Akita Univ School of Medicine, 1-1-1 Hondo, Akita 010-8543, Japan), Zhuang Y-J, Singh TM, Kawamura K, Murakami M, Zarins CK, Glagov S—Arterioscler Thromb Vasc Biol. 1999;19:2298–2307. Copyright © 1999 American Heart Association.
Gaps in the internal elastic lamina (IEL) have been observed in arteries exposed to high blood flow. To characterize the nature and consequences of this change, blood flow was increased in the carotid arteries of 56 adult, male, Japanese white rabbits by creating an arteriovenous fistula between the common carotid artery and the external jugular vein. The common carotid artery proximal to the arteriovenous fistula was studied at intervals from 1 hour to 8 weeks after exposure to high flow. In the controls, the IEL showed only the usual, small, physiological holes, 2 to 10 μm in diameter. At 3 days, some of the holes in the IEL had become enlarged, but they could not be detected by scanning electron microscopy, despite manifest endothelial cell proliferation. At 4 days, gaps in the IEL appeared as small, luminal surface depressions, 15 to 50 μm wide. At 7 days, the gaps in the IEL had enlarged and formed circumferential, luminal depressions occupying 15±5% of the lumen surface. Endothelial cell proliferation persisted in the gaps while proliferative activity decreased where the IEL remained intact. At 4 weeks, as the artery became elongated and dilated, the gaps in the IEL widened as intercommunicating circumferential and longitudinal luminal depressions occupying 64±5% of the lumen surface. At 8 weeks, the rate of elongation and dilatation of the artery slowed and the widening of the gaps in the IEL diminished. Endothelial cells covered the gaps throughout. We conclude that flow-induced arterial dilatation is accompanied by an adaptive remodeling of the intima. The gaps in the IEL permit an increase in lumen surface area while endothelial cell proliferation assures a continuous cell lining throughout.
Key Words: vasomotor reactivity, arterial wall
The Direct Antiatherogenic Effect of Estrogen Is Present, Absent, or Reversed, Depending on the State of the Arterial Endothelium: A Time Course Study in Cholesterol-Clamped Rabbits—Holm P (Dept of Women’s Healthcare Biology, Novo Nordisk Park, 2760 Måløv, Denmark), Andersen HL, Andersen MR, Erhardtsen E, Stender S—Circulation. 1999;100:1727–1733. Copyright © 1999 American Heart Association, Inc.
Background—This study further investigated the relationship between estrogen, arterial endothelium, and nitric oxide (NO) in cholesterol-clamped rabbits.
Methods and Results—Rabbits were ovariectomized, balloon-injured in the thoracic aorta, and grouped to receive cholesterol-enriched chow together with either 17β-estradiol or vehicle for 1, 2, 4, or 8 weeks. In the undamaged aorta, cholesterol accumulation of the placebo rabbits was significantly increased from week 4 to 8 (P<0.001). This increase was almost completely inhibited by estrogen (P<0.001). In the balloon-injured aorta, the estrogen and placebo rabbits accumulated similar amounts of cholesterol in the reendothealized areas. In the deendothelialized areas, the estrogen group surprisingly accumulated significantly more cholesterol than the placebo group. This difference was apparent from week 2 and became significant at week 8 (P<0.01). Circulating nitrite/nitrate were significantly increased by estrogen at weeks 1, 2, and 4 but not at week 8. Similarly, in additional experiments, basal NO release was significantly higher in estrogen-treated than in placebo-treated rabbits after 4 (P<0.05) but not after 8 weeks. Stimulated NO release and endothelial NO synthase activity did not differ between groups. Mononuclear-endothelial cell binding was reduced by 50% by estrogen after 4 weeks (P<0.05). This difference, however, was abolished by coadministration of NG-nitro-l-arginine methyl ester, an inhibitor of NO production.
Conclusions—The direct antiatherogenic effect of estrogen was present, absent, or reversed, depending on the state of the arterial endothelium, and preceded by a transient increase in NO production followed by a reduced mononuclear-endothelial cell binding.
Key Words: atherosclerosis, estrogens
A Comparison of Fast Spin-Echo, Fluid-Attenuated Inversion-Recovery, and Diffusion-Weighted MR Imaging in the First 10 Days After Cerebral Infarction—Ricci PE (Wake Forest Univ, Bowman Gray School of Medicine, Dept of Radiology, Winston-Salem, NC 27157), Burdette JH, Elster AD, Reboussin DM—AJNR Am J Neuroradiol. 1999;20:1535–1542.
BACKGROUND AND PURPOSE: Echo-planar diffusion-weighted and fluid-attenuated inversion-recovery (FLAIR) imaging have both proved valuable for detecting acute ischemic infarcts, but little is known about the value of diffusion-weighted imaging beyond the acute infarct period. Furthermore, no direct comparison of the techniques has been published. We compared the diagnostic utility of diffusion-weighted, FLAIR, and T2-weighted fast spin-echo (FSE) imaging for detecting cerebral infarctions up to 10 days old.
METHODS: FSE, FLAIR, and diffusion-weighted MR sequences were obtained prospectively over a 6-month period in 212 patients with suspected cerebral infarctions. Seventy patients with nonhemorrhagic ischemic infarcts less than 10 days old whose symptoms lasted longer than 48 hours were identified. The three sequences were compared for detectability and conspicuity of abnormalities that correlated with the neurologic deficit.
RESULTS: Seventy-two symptomatic infarcts were found in the 70 patients, Diffusion-weighted imaging detected 70 (97%), FLAIR, 69 (96%), and FSE, 64 (89%) of the 72 lesions. Only the difference between diffusion-weighted and FSE imaging approached statistical significance. There was no difference in the number of lesions detected in the patients imaged 48 hours or more after infarction. Lesion conspicuity on diffusion-weighted images was judged superior to that on FSE and FLAIR images in 55 (77%) and 47 (67%) of the cases, respectively. FLAIR images were judged superior to FSE in 34 (48%) of the cases.
CONCLUSION: Diffusion-weighted images showed more infarcts than FLAIR and FSE images, and FLAIR images showed more than FSE images, but the differences were not statistically significant. Lesion conspicuity, however, was consistently better on diffusion-weighted images than on either FLAIR or FSE images throughout the III-day period. Acquisition of diffusion-weighted images in the late acute and subacute periods after ischemic cerebral infarction appears to be beneficial.
Key Words: cerebral infarction, magnetic resonance imaging
Longitudinal Magnetic Resonance Imaging Study of Perfusion and Diffusion in Stroke: Evolution of Lesion Volume and Correlation With Clinical Outcome—Beaulieu C, de Crespigny A, Tong DC, Moseley ME, Albers GW, Marks MP (Dept of Radiology, Stanford Univ Medical Center, 300 Pasteur Dr, Stanford, CA 94305-5105)—Ann Neurol. 1999;46:568–578. Copyright © 1999 by the American Neurological Association.
A prospective longitudinal diffusion-weighted and perfusion-weighted magnetic resonance imaging (DWI/PWI) study of stroke patients (n=21) at five distinct time points was performed to evaluate lesion evolution and to assess whether DWI and PWI can accurately and objectively demonstrate the degree of ischemia-induced deficits within hours after stroke onset. Patients were scanned first within 7 hours of symptom onset and then subsequently at 3 to 6 hours, 24 to 36 hours, 5 to 7 days, and 30 days after the initial scan. Lesion evolution was dynamic during the first month after stroke. Most patients (18 of 19, 95%) showed increased lesion volume over the first week and then decreased at 1 month relative to 1 week (12 of 14, 86%). Overall, lesion growth appeared to depend on the degree of mismatch between diffusion and perfusion at the initial scan. Abnormal volumes on the acute DWI and PWI (<7 hours) correlated well with initial National Institutes of Health (NIH) stroke scale scores, outcome NIH stroke scale scores, and final lesion volume. DWI and PWI can provide an early measure of metabolic and hemodynamic insufficiency, and thus can improve our understanding of the evolution and outcome after acute ischemic stroke.
Key Words: magnetic resonance imaging, cerebral ischemia
The Value of Acetazolamide Single Photon Emission Computed Tomography Scans in the Preoperative Evaluation of Asymptomatic Critical Carotid Stenosis—Cikrit DF (Dept of Surgery, Indiana Univ School of Medicine, 1001 W 10th ST, OPE 310, Indianapolis, IN 46202), Dalsing MC, Lalka SG, Burt RW, Sawchuk AP, Solooki BA—J Vasc Surg. 1999;30:599–605. Copyright © 1999 by the Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter.
Purpose: Acetazolamide (ACZ)-enhanced single photon emission computed tomography (SPECT) scans can assess both cerebral perfusion and vascular reactivity. Patients with asymptomatic critical carotid artery stenosis were evaluated for cerebral vascular reactivity to determine the effect of extracranial occlusive disease and the effect of carotid endarterectomy (CEA) on intracerebral reactivity.
Methods: In 44 patients with asymptomatic critical carotid artery stenosis, cerebral perfusion and vascular reactivity were assessed before CEA with resting and ACZ-enhanced SPECT scans. All patients had a 70% or greater ipsilateral internal carotid artery stenosis. Preoperative ACZ-enhanced SPECT scans were obtained, usually 5 days before CEA. Postoperative ACZ-enhanced SPECT scans were obtained in 30 patients.
Results: Preoperative SPECT scans were asymmetric, revealing focal (n=19) or global (n=15) decreased reactivity in 34 patients (77%). Ten patients had symmetric or normal reactivity. After CEA, 23 patients demonstrated an improvement in reactivity ipsilateral to the side of surgery. The remaining seven patients failed to improve after surgery.
Conclusion: Although all patients had a high-grade internal carotid stenosis, nearly a quarter of the patients had excellent intracerebral collateral flow. Only 71% of patients demonstrated improved intracerebral vasoreactivity after CEA. The lack of improvement in the other patients may have resulted from intracerebral pathology or lack of improvement in the extracranial carotid hemodynamics.
Key Words: vasomotor reactivity, carotid stenosis
Comprehensive MR Imaging Protocol for Stroke Management: Tissue Sodium Concentration as a Measure of Tissue Viability in Nonhuman Primate Studies and in Clinical Studies—Thulborn KR (MR Research Center, Presbyterian Univ Hospital, B855, 200 Lothrop St, Pittsburgh, PA 15213-2582, email:email@example.com), Gindin TS, Davis D, Erb P—Radiology. 1999;213:156–166.
PURPOSE: To investigate sodium magnetic resonance (MR) imaging for monitoring tissue viability in stroke.
MATERIALS AND METHODS: A comprehensive MR imaging protocol used to measure apparent diffusion coefficient and perfusion parameters was extended to include sodium imaging. Tissue sodium concentration was estimated by using a two-compartment model. This protocol lasted less than 45 minutes. These parameters were followed over the first 6 hours in a nonhuman primate model (n=2) of acute embolic stroke without or with thrombolytic therapy. This protocol was used in patients in whom acute (<24 hours, n=11) or nonacute (≥24 hours, n=31) stroke was ultimately confirmed.
RESULTS: The animal model showed abnormal diffusion and perfusion parameters in the lesion immediately after embolization, and these remained abnormal for over 6 hours. Tissue sodium concentration increased with time (5.7 mmol/L/h) unless halted with thrombolytic therapy. Regions with sodium concentrations over 70 mmol/L were histochemically verified as being infarcted. In patients in whom stroke older than 6 hours was clinically confirmed, sodium concentrations over 70 mmol/L were found in the appropriate brain regions.
CONCLUSION: Tissue sodium concentration provides a sensitive measure of tissue viability that is complementary to the diagnostic role of diffusion and perfusion imaging for ischemic insult.
Key Words: magnetic resonance imaging, cerebral ischemia
Comparison of Transcranial Color-Coded Duplex Sonography and Cranial CT Measurements for Determining Third Ventricle Midline Shift in Space-Occupying Stroke—Stolz E (Univ of Giessen, Dept of Neurology, Steg 14, D-35385 Giessen, Germany), Gerriets T, Fiss I, Babacan SS, Seidel G, Kaps M—AJNR Am J Neuroradiol. 1999;20:1567–1571.
BACKGROUND AND PURPOSE: Transcranial color-coded duplex sonography (TCCS) allows the noninvasive, easily reproducible measurement of midline dislocation (MLD) of the third ventricle in space-occupying stroke, even in critically ill patients. However, the method has been validated only in a small number of subjects. The aim of this study was to test the method under clinical conditions.
METHODS: In 61 prospectively recruited patients (mean age, 62±15 years) with supratentorial ischemic infarction or intracranial hemorrhage, the sonographic measurement of MLD was compared with cranial CT data in a 12-hour time window. Subgroup analysis was also undertaken for comparing TCCS and cranial CT measurements within a 3-hour time window.
RESULTS: One hundred twenty-two data pairs of TCCS and cranial CT MLD measurements were correlated within the 12-hour time window. TCCS and cranial CT measurements of MLD correlated both in the total patient group and in the different subgroups with coefficients of over 0.9. The 2-SD confidence interval of the difference between the TCCS measurements and the respective means of both methods in the total patient collective was ±1.78 mm.
CONCLUSION: TCCS provides a noninvasive, easily reproducible and reliable method for monitoring MLD of the third ventricle in stroke patients. It is particularly suitable for critically ill patients who are not fit for transportation.
Key Words: stroke assessment, ultrasonography
Vasoneuronal Coupling in Migraineurs After Subcutaneous Sumatriptan: A TCD Study—Baezner H (Dept of Neurology, Univ Heidelberg, Klinikum Mannheim, 68135 Mannheim, Germany), Steinke W, Daffertshofer M, Hennerici M—J Neurol Sci. 1999;167:50–55. Copyright © 1999 Elsevier Science B.V.
According to the trigeminovascular model of pain in migraine, sterile neurogenic inflammation of dural vessels stimulates nociceptive fibres of the trigeminal nerve. Sumatriptan, a 5-HT1 receptor agonist, blocks this reaction and mediates vasoconstriction of meningeal arteries. However, it is uncertain, whether sumatriptan also has a vasoconstrictive effect on cerebral arteries, which may influence vasoneuronal coupling and induce secondary cerebral blood flow changes. We studied changes of cerebral blood flow velocity (CBFV) and the pulsatility index (PI) in the posterior cerebral artery (PCA) after stimulus activation before, 10 min and 30 min after subcutaneous application of 6 mg sumatriptan, in order to assess potential vasoactive effects on cerebral circulation. CBFV was recorded from both PCAs simultaneously in 27 migraineurs (twenty women, seven men, mean age 29 years), and arterial blood pressure (BP), heart rate (HR) and respiration rate (RR) were monitored. Although the mean diastolic blood pressure rose significantly from 75 mm Hg to 81 mm Hg (P<0.05) and systolic blood pressure and respiration rates remained constant, average CBFV values remained constant. Similarly, the relative increase of CBFV by visual stimulation, which is clearly higher compared to controls in other studies (55.0% before, 52.6% after 10 min, and 52.4% after 30 min), and absolute mean values for CBFV and PI did not change after visual stimulation. These results provide evidence against the hypothesis that sumatriptan produces vasoconstriction in the intracranial human arterial circulation as a potential risk of cerebral ischemia.
Key Words: vasomotor reactivity, migraine
Antithrombotic Therapy to Prevent Stroke in Patients With Atrial Fibrillation: A Meta Analysis—Hart RG (Dept of Medicine, Univ of Texas Health Science Center, 7703 Floyd Curl Dr, San Antonio, TX 78284), Benavente O, McBride R, Pearce LA—Ann Intern Med. 1999;131:492–501. Copyright © 1999 American College of Physicians-American Society of Internal Medicine.
Purpose: To characterize the efficacy and safety of anticoagulants and antiplatelet agents for prevention of stroke in patients with atrial fibrillation.
Data Sources: Randomized trials identified by using the search strategy developed by the Cochrane Collaboration Stroke Review Group.
Study Selection: All published randomized trials testing antithrombotic agents to prevent stroke in patients with atrial fibrillation.
Data Extraction: Data on interventions, number of participants, duration of exposure and occurrence of all stroke (ischemic and hemorrhagic), major extracranial bleeding, and death were extracted independently by two investigators.
Data Synthesis: Sixteen trials included a total of 9874 participants (mean follow-up, 1.7 years). Adjusted-dose warfarin (six trials, 2900 participants) reduced stroke by 62% (95% CI, 48% to 72%); absolute risk reductions were 2.7% per year for primary prevention and 8.4% per year for secondary prevention. Major extracranial bleeding was increased by warfarin therapy (absolute risk increase, 0.3% per year). Aspirin (six trials, 3119 participants) reduced stroke by 22% (CI, 2% to 38%); absolute risk reductions were 1.5% per year for primary prevention and 2.5% per year for secondary prevention. Adjusted-dose warfarin (five trials, 2837 participants) was more efficacious than aspirin (relative risk reduction, 36% [CI, 14% to 52%]). Other randomized comparisons yielded inconclusive results.
Conclusions: Adjusted-dose warfarin and aspirin reduce stroke in patients with atrial fibrillation, and warfarin is substantially more efficacious than aspirin. The benefit of antithrombotic therapy was not offset by the occurrence of major hemorrhage among participants in randomized trials. Judicious use of antithrombotic therapy, tailored according to the inherent risk for stroke, importantly reduces stroke in patients with atrial fibrillation.
Key Words: anticoagulants, atrial fibrillation
Primary Prevention of Arterial Thromboembolism in Non-Rheumatic Atrial Fibrillation in Primary Care: Randomised Controlled Trial Comparing Two Intensities of Coumarin With Aspirin—Hellemons BS (Dept of General Practice, Univ of Maastricht, PO Box 616, NL-6200 MD Maastricht, Netherlands), Langenberg M, Lodder J, Vermeer F, Schouten HJ, Lemmens T, van Ree JW, Knottnerus JA—BMJ. 1999;319:958–964.
Objective To investigate the effectiveness of aspirin and coumarin in preventing thromboembolism in patients with non-rheumatic atrial fibrillation in general practice.
Design Randomised controlled trial.
Participants 729 patients aged greater than or equal to 60 years with atrial fibrillation, recruited in general practice, who had no established indication for coumarin. Mean age was 75 years and mean follow up 2.7 years.
Setting Primary care in the Netherlands. Interventions Patients eligible for standard intensity coumarin (international normalised ratio 2.5–3.5) were randomly assigned to standard anticoagulation, very low intensity coumarin (international normalised ratio 1.1–1.6), or aspirin (150 mg/day) (stratum 1). Patients ineligible for standard anticoagulation were randomly assigned to low anticoagulation or aspirin (stratum 2).
Main outcome measures Strike, systemic embolism, major haemorrhage, and vascular death.
Results 108 primary events occurred (annual event rate 5.5%), including 13 major haemorrhages (0.7% a year). The hazard ratio was 0.91 (0.61 to 1.36) for low anticoagulation versus aspirin and 0.78 (0.34 to 1.81) for standard anticoagulation versus aspirin. Non-vascular death it as less common in die low anticoagulation Ir;roup than in die aspirin group (0.41, 0.20 to 0.82). There was no significant difference between the treatment groups in bleeding incidence. High systolic and lo iv diastolic blood pressure and age were independent prognostic factors.
Conclusion In a general practice population (without established indications for coumarin) neither low nor standard intensity anticoagulation is better than aspirin in preventing primary outcome events. Aspirin may therefore be the first choice in patients with atrial fibrillation in general practice.
Key Words: atrial fibrillation, anticoagulants
Protruding Aortic Arch Atheromas: Risk of Stroke During Heart Surgery With and Without Aortic Arch Endarterectomy—Stern A, Tunick PA (Noninvasive Cardiology Laboratory, NYU Medical Center, 560 First Ave, New York, NY 10016), Culliford AT, Lachmann J, Baumann FG, Kanchuger MS, Marschall K, Shah A, Grossi E, Kronzon I—Am Heart J. 1999;138:746–752. Copyright © 1999 by Mosby, Inc.
Background Stroke occurs in 1% to 7% of heart surgery. Aortic arch atherosclerosis is a risk factor for intraoperative stroke, and endarterectomy has been proposed to prevent stroke during heart surgery in patients with arch atheromas.
Methods and Results Intraoperative transesophageal echocardiography was performed in 3404 patients undergoing heart surgery between 1990 and 1996. Use of transesophageal echocardiography was unselected and based on equipment availability. Aortic arch atheromas (≥5 mm, or mobile) were seen in 268 (8%) patients. They were evaluated for intraoperative stroke (confirmed by a neurologist and cerebral infarction on computed tomography or magnetic resonance imaging). Arch endarterectomy was performed in 43 patients as an adjunct to their cardiac procedure in an attempt to prevent intraoperative stroke. The intraoperative stroke rate in all 268 patients with atheromas was high (15.3%). On univariate analysis, age, previous stroke, and arch endarterectomy were significantly associated with intraoperative stroke. On multivariate analysis, age (odds ratio 3.9, P=.01) and arch endarterectomy (odds ratio 3.6, P=.001) were independently predictive of intraoperative stroke. Mortality rate in all 268 patients was high (14.9%). These patients with atheromas also had a long recovery room, intensive care unit, and total hospital length of stay (48 days).
Conclusions Patients with protruding aortic arch atheromas are at high risk for intraoperative stroke, significant and multiple morbidity, prolonged hospital stay, and death resulting from heart surgery. Aortic arch endarterectomy is strongly associated with intraoperative stroke; its use should be carefully considered in light of these results.
Key Words: aortic arch, atherosclerosis
Surgical Decision Making for Carotid Endarterectomy and Contemporary Magnetic Resonance Angiography—Ozaki CK (Sec of Vascular Surgery, Dept of Surgery, PO Box 100286, Gainesville, FL 32610-0286), Irwin PB, Flynn TC, Huber TS, Seeger JM—Am J Surg. 1999;178:182–184. Copyright © 1999 by Excerpta Medica, Inc.
background: Benefit from carotid endarterectomy (CEA) centers on patient selection and percent stenosis as determined by cerebral angiography. However, angiography remains expensive and poses risks. Validated carotid duplex ultrasonography has proven to be an accurate tool for selecting patients for CEA. However, the role of another noninvasive test—magnetic resonance angiography (MRA)—remains uncertain. Because of recent advances in MRA hardware and software, we hypothesized that clinically appropriate patients could be accurately selected for CEA based on MRA alone.
methods: Fifty-four carotid arteries in 29 patients (with and without symptoms) underwent both three-dimensional time-of-flight MRA (1.5 Tesla) with multiple overlapping thin slab acquisition and biplanar intra-arterial digital subtraction angiography. All patients undergoing both tests over a 24-month period were included. The majority of these patients did not undergo carotid duplex ultrasound owing to the clinical practice of the hospital’s neurosurgery service. Staff radiologists interpreted each study. The accuracy of patient selection based on MRA was calculated using angiography as the standard (NASCET method). Since operative thresholds vary depending on clinical history, we considered four commonly used ranges of percent stenosis for CEA.
results: Patient selection accuracy of MRA alone was low, but increased as percent stenosis increased. Out of 10 occluded arteries by angiography, 5 were interpreted as patient with stenosis (70% to 99%) by MRA. One patent artery was misread as occluded on MRA.
conclusion: Reliance solely on contemporary MRA for surgical decision making cannot be justified in view of low accuracy, which leads to high rates of error in patient selection for CEA.
Key Words: magnetic resonance imaging, carotid endarterectomy
Perioperative Risk and Late Outcome of Nonelective Carotid Endarterectomy—Tretter JF, Hertzer NR (Dept of Vascular Surgery, The Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195), Mascha EJ, O’Hara PJ, Krajewski LP, Beven EG—J Vasc Surg. 1999;30:618–631. Copyright © 1999 by the Society for Vascular Surgery and International Society for Cardiovascular Surgery and International Society for Cardiovascular Surgery, North American Chapter
Purpose: In an earlier report of our database for 1924 isolated carotid endarterectomies (CEAs) from 1989 to 1995, multivariable analysis results indicated that the urgency of operation unfavorably influenced the combined stroke and mortality rate (CSM). This study was conducted in an attempt to document the features that contribute to perioperative complications and late outcome in 314 patients for whom CEA was considered to be nonelective because of the severity of previous symptoms, carotid stenosis or medical comorbidities.
Methods: All the hospital charts and outpatient records were reviewed retrospectively for the 209 men and 105 women who had undergone nonelective CEAs (median age, 69 years). Information regarding the clinical risk factors, the operative indications (CHAT classification), the severity and distribution of carotid disease, and the surgical management were analyzed to assess the impact on the 30-day CSM and on the long-term survival rate and neurologic events during a median follow-up period of 34 months.
Results: Previous symptoms had occurred in 285 patients (91%) and included cortical transient ischemic attacks in 47%, amaurosis fugax in 20%, completed strokes in 14%, unstable strokes in 2%, and nonspecific or miscellaneous symptoms in 8%. Preoperative angiography was performed in 308 patients (98%), which confirmed the presence of 80% to 99% ipsilateral carotid stenosis in 79% of the patients and >90% stenosis in 43%. The median interval between presentation and surgical treatment was 2 days, but 48% of the 314 CEAs were performed within 24 hours of presentation. The 30-day CSM was 6.7% and ranged from 3.4% for 29 patients with severe asymptomatic carotid stenosis to 14% for those patients with unstable strokes. The cardiac and pulmonary risk factors were the only variables that were related statistically to the CSM. During the follow-up period, the risk for ipsilateral stroke was significantly higher in women (risk ratio [RR], 2.38; 95% confidence interval [CI], 1.02 to 5.56; P=.04) and in patients with higher gradients of cardiac and pulmonary risk factors (RR, 2.8; 95% CI, 1.6 to 4.8 per gradient increase; P<.001). The risk was significantly lower in patients who had undergone vein patch angioplasty (RR, 0.29; 95% CI, 0.12 to 0.71; P=.006) in comparison with synthetic patching. However, 38 of the 55 patients (69%) who underwent synthetic patching also had widespread atherosclerosis for which the saphenous veins already had been harvested for coronary bypass grafting surgery or infrainguinal revascularization.
Conclusion: In our experience, the perioperative risk of nonelective CEA primarily is determined by incidental cardiopulmonary disease. Vein patch angioplasty appears to enhance late results, but the late stroke rate associated with synthetic patching also may have been influenced by the extent of vascular disease in our study group.
Key Words: carotid endarterectomy, stroke management
Emergency Carotid Thromboendarterectomy: Safe and Effective—Schneider C (Dept of Visceral, Trauma, and Vascular Surgery, Krankenhaus der Barmherzigen Brüder, Teaching Hospital of the Univ of Mainz, Nordallee 1, 54292 Trier, Germany), Johansen K, Königstein R, Metzner C, Oettinger W—World J Surg. 1999;23:1163–1167. Copyright © 1999 by the Société International de Chirurgie.
Whether to perform emergency carotid thromboendarterectomy (CTEA) in the presence of crescendo transient ischemic attacks or stroke-in-evolution is controversial, with the operative mortality in some reports exceeding 20% and improvement in neurologic deficit of less than 40% in others. Our anecdotal experience with emergency CTEA for acute, persistent, or crescendo neurologic deficit had been strikingly better than published reports. Accordingly, we carried out a retrospective comparison of 43 such patients undergoing emergency CTEA with 237 patients concurrently undergoing elective CTEA for conventional indications. A standard protocol followed in emergency CTEA patients included carotid Doppler ultrasonography, computed cerebral tomography (CT), four-vessel cerebral arteriography, and intravenous heparin. Exclusions from emergency CTEA included coma or cerebral CT scan evidence for either hemorrhagic or ischemic infarction with edema. Operative techniques included standard carotid endarterectomy with Dacron patch or direct suture, eversion endarterectomy, or shortening resection. No mortality or central neurologic complications resulted among the 43 emergency CTEA patients, in comparison to no deaths and one temporary hemiparesis (0.4% central neurologic morbidity) in the 237 elective CTEA patients. Our results suggest that in the absence of coma or cerebral CT scan evidence for an unstable blood-brain barrier, emergency carotid reconstruction can be performed safely and with excellent outcome notwithstanding the magnitude and severity of the acute preoperative neurologic deficit.
Key Words: carotid endarterectomy, stroke management
Items of Interest
Effect of Batroxobin on Spontaneous Echo Contrast and Hemorheology in Left Atrial Appendage in Atrial Fibrillation Assessed by Transesophageal Echocardiography—Sakamoto S, Mizushige K (2nd Dept of Internal Medicine, Kagawa Medical Univ, 1750-1, Miki, Kita, Kagawa, 761-0793, Japan), Takagi Y, Ueda T, Ohmori K, Matsuo H—Am J Cardiol. 1999;84:816–819. Copyright © 1999 by Excerpta Medica, Inc.
Bilateral Intracranial Vertebral Artery Disease in the New England Medical Center Posterior Circulation Registry—Shin H-K, Yoo K-M, Chang HM, Caplan LR (Dept of Neurology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215)—Arch Neurol. 1999;56:1353–1358.
Recent Progress in Drug Treatment for Acute Stroke—Devuyst G, Bogousslavsky J (CHUV, Dept of Neurology, Rue du Bugnon, 1011 Lausanne, Switzerland)—J Neurol Neurosurg Psychiatry. 1999;67:420–425.
Extracranial Vertebral Artery Stent Placement: In-Hospital and Follow-Up Results—Chastain HD, Campbell MS, Iyer S, Roubin GS, Vitek J, Mathur A, Al-Mubarak NA, Terry JB, Yates V, Kretzer K, Alred D, Gomez CR (Comprehensive Stroke Center, Univ of Alabama at Birmingham, 1202 Jefferson Tower and 625 S 19th St, Birmingham, AL 35294)—J Neurosurg. 1999;91:547–552.
Refining the Indications for Carotid Endarterectomy in Patients With Symptomatic Carotid Stenosis: A Systematic Review—Cinà CS (Victoria Medical Centre, 304 Victoria Ave N, Ste 305, Hamilton, ON, Canada L8L 5G4), Clase CM, Haynes BR—J Vasc Surg. 1999;30:606–617. Copyright © 1999 by the Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter.
Measuring Quality of Life in a Way That Is Meaningful to Stroke Patients—Williams LS (Roudebush VAMC, HSR&D, 11-H, 1481 West 10th St, Indianapolis, IN 46202), Weinberger M, Harris LE, Biller J—Neurology. 1999;53:1839–1843. Copyright © 1999 by the American Academy of Neurology.
Light-To-Moderate Alcohol Consumption and the Risk of Stroke Among US Male Physicians—Berger K, Ajani UA, (Div of Preventive Medicine, Brigham and Women’s Hospital, 900 Commonwealth Ave E, Boston, MA 02215), Kase CS, Gaziano JM, Buring JE, Glynn RJ, Hennekens CH—N Engl J Med. 1999;341:1557–1564. Copyright © 1999, Massachusetts Medical Society.
Risks and Benefits of Screening for Intracranial Aneurysms in First-Degree Relatives of Patients With Sporadic Subarachnoid Hemorrhage—The Magnetic Resonance Angiography in Relatives of Patients With Subarachnoid Hemorrhage Study Group (Dr Dianne Raaymakers, Dept of Neurology, H2.128, Univ Hospital Utrecht, Heidelberglaan 100, 3584 CX Utrecht, Netherlands)—N Engl J Med. 1999;341:1344–1350.
Antithrombotic Treatments in Acute Ischemic Stroke—del Zoppo GJ (The Scripps Research Institute and Div of Hematology/Medical Oncoogy, Scripps Clinic and Research Foundation, 10550 N Torrey Pines Rd, SBR-17, La Jolla, CA 92037)—Thromb Haemost. 1999;82:938–946.
- Copyright © 2000 by American Heart Association