RESUMEN
Acetylcholine (ACh) is a crucial neurotransmitter that is involved in airway constriction. In fact, excessive ACh binding to M3 muscarinic receptor leads to airflow obstruction via smooth muscle contraction. Previous studies have suggested cholinergic malfunction in the pathogenesis of asthma; however, the distribution and abundance of ACh in asthmatic lungs remain unclear because of the challenges of imaging ACh in lung tissue. In this study, we successfully detected and visualised ACh in mouse lung tissue by using Fourier transform ion cyclotron resonance mass spectrometry (FT-ICR-MS). Here, we applied the ACh imaging method to the two groups of house dust mite-sensitised asthma model mice harbouring different inflammatory levels. The imaging results showed that the lungs of mice had a relatively uniform ACh distribution with some areas of heterogeneity. The lungs of asthma model mice had significantly more ACh than control mice, and the ACh increase was potentiated with intense eosinophil infiltration without acetylcholinesterase deficits. These results indicate that ACh hypersecretion is mediated by an increased infiltration of eosinophils in asthma aggravation. This study provides the first evidence that secreted ACh is elevated with asthma severity in the lungs of asthma model animals by a direct ACh imaging technique with FT-ICR-MS.
Asunto(s)
Acetilcolina/análisis , Asma/patología , Pulmón/patología , Espectrometría de Masas/métodos , Animales , Modelos Animales de Enfermedad , Femenino , Análisis de Fourier , Pulmón/química , Ratones Endogámicos BALB CRESUMEN
Successful treatment for respiratory diseases relies on effective delivery of medication to the lungs using an inhalation device. Different inhalers have distinct characteristics affecting drug administration and patient adherence, which can impact clinical outcomes. We report on the development of the Respimat® soft mist inhaler (SMI) and compare key attributes with metered-dose inhalers (MDIs) and dry powder inhalers (DPIs). The Respimat SMI, a pocket-sized device generating a single-breath, inhalable aerosol, was designed to enhance drug delivery to the lungs, reduce the requirements for patient coordination and inspiratory effort, and improve the patients' experience and ease of use. The drug deposition profile with Respimat SMI is favorable compared with MDIs and DPIs, with higher drug deposition to the lung and peripheral airways. The slow velocity and long spray duration of the Respimat SMI aerosol also aid patient coordination. Clinical equivalence has been demonstrated for maintenance treatment of chronic obstructive pulmonary disease using once-daily tiotropium between Respimat SMI (5 µg) and HandiHaler DPI (18 µg). In comparative studies, patients preferred Respimat SMI to MDIs and DPIs; they reported that Respimat SMI was easy to use and felt the inhaled dose was delivered. The Respimat SMI, designed to generate a slow-moving and fine mist, is easy to use and effectively delivers drug treatment to the lungs. The patient-centered design of Respimat SMI improved patient satisfaction, and may help to promote long-term adherence and improve clinical outcomes with asthma and chronic obstructive pulmonary disease.
Asunto(s)
Combinación Albuterol y Ipratropio/administración & dosificación , Broncodilatadores/administración & dosificación , Sistemas de Liberación de Medicamentos/métodos , Diseño de Equipo/métodos , Inhaladores de Dosis Medida , Administración por Inhalación , Combinación Albuterol y Ipratropio/metabolismo , Asma/tratamiento farmacológico , Asma/metabolismo , Broncodilatadores/metabolismo , Sistemas de Liberación de Medicamentos/instrumentación , Humanos , Enfermedad Pulmonar Obstructiva Crónica/tratamiento farmacológico , Enfermedad Pulmonar Obstructiva Crónica/metabolismoRESUMEN
BACKGROUND: The purpose of the present study was to investigate whether resolution of crossed cerebellar hypoperfusion (CCH) and increase in (123)I-iomazenil (IMZ) uptake in the ipsilateral cerebral cortex after carotid endarterectomy (CEA) are associated with postoperative improvement of cognitive function. METHODS: Neuropsychological testing was performed preoperatively and after 1 postoperative month in 79 patients undergoing CEA for ipsilateral internal carotid artery stenosis (>or=70%). Brain perfusion single photon emission computed tomography (SPECT) using N-isopropyl-p-(123)I-iodoamphetamine and (123)I-IMZ SPECT were also performed before and after surgery. Data were analyzed using a three-dimensional stereotaxic region of interest template. RESULTS: Seven patients (9%) showed improvement in postoperative cognitive function. All the 7 patients exhibited both postoperative increase in blood flow in the ipsilateral cerebral cortex and resolution of CCH. Five patients (6%) had a postoperative hemispheric increase in (123)I-IMZ uptake, and cognitive function improved in all of these 5 patients. Analysis by a receiver operating characteristic (ROC) curve was used to estimate the ability to discriminate between patients with and without postoperative cognitive improvement. The area under the ROC curve was significantly greater when analyzing the magnitude of postoperative resolution of CCH (0.991; 95% CI 0.984-1.001) or postoperative hemispheric increase in (123)I-IMZ uptake (0.981; 95% CI 0.972-0.999) when compared with the magnitude of postoperative increase in cerebral blood flow (0.929; 95% CI 0.886-0.971) (p < 0.05). CONCLUSIONS: Resolution of CCH and increase in (123)I-IMZ uptake in the ipsilateral cerebral cortex after CEA is associated with postoperative improvement in cognitive function. These results may indicate that cognitive impairment is related to a state of potentially reversible central benzodiazepine receptor downregulation in the cortex in response to transient ischemic attack or minor stroke.
Asunto(s)
Estenosis Carotídea/cirugía , Cerebelo/irrigación sanguínea , Corteza Cerebral/diagnóstico por imagen , Trastornos del Conocimiento/prevención & control , Endarterectomía Carotidea , Flumazenil/análogos & derivados , Radioisótopos de Yodo , Isquemia/fisiopatología , Receptores de GABA-A/metabolismo , Tomografía Computarizada de Emisión de Fotón Único , Adulto , Vías Aferentes/fisiopatología , Anciano , Arteria Carótida Interna/cirugía , Estenosis Carotídea/psicología , Cerebelo/fisiopatología , Corteza Cerebral/fisiopatología , Trastornos del Conocimiento/etiología , Dominancia Cerebral , Regulación hacia Abajo , Femenino , Flumazenil/farmacocinética , Humanos , Radioisótopos de Yodo/farmacocinética , Isquemia/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Pruebas Neuropsicológicas , Curva ROC , Resultado del TratamientoRESUMEN
BACKGROUND AND OBJECTIVE: In animal models, the magnitude of early post-ischemic hyperemia tends to correlate with the duration and intensity of prior ischemic insult. The aim of this study was to determine whether early post-ischemic hyperemia in human brain during carotid endarterectomy (CEA) is associated with the severity of cerebral ischemic insult during clamping of the internal carotid artery (ICA). METHODS: Transcranial cerebral oxygen saturation using near-infrared spectroscopy was monitored intraoperatively in 171 patients undergoing CEA for ipsilateral ICA stenosis (>70%) to assess the intensity of cerebral hemispheric ischemia during ICA clamping and the magnitude of early post-ischemic hyperemia after ICA declamping. RESULTS: Early post-ischemic hyperemia peaked within 3 minutes after ICA declamping and resolved at 20 minutes after ICA declamping. A significant correlation was observed between the magnitude of early post-ischemic hyperemia and the intensity of cerebral ischemia (r=0.697; p<0.0001). Eight patients recovered from anesthesia with a new minor neurological deficit on the side contralateral to the CEA (4.7%). Analysis by receiver operating characteristics (ROC) curve was used to estimate the ability to discriminate between patients with and without post-operative development of new neurological deficits. Area under the ROC curve was significantly greater when analysing the magnitude of early post-ischemic hyperemia (1.00; 95% CI: 0.99-1.00) when compared with the intensity of cerebral ischemia (0.93; 95% CI: 0.89-0.98) (p<0.01). CONCLUSION: Early post-ischemic hyperemia in CEA is correlated with the severity of cerebral ischemic insult during clamping of the ICA.
Asunto(s)
Isquemia Encefálica/etiología , Isquemia Encefálica/fisiopatología , Circulación Cerebrovascular/fisiología , Endarterectomía Carotidea/métodos , Hiperemia/etiología , Monitoreo Intraoperatorio/efectos adversos , Complicaciones Posoperatorias/fisiopatología , Adulto , Anciano , Estenosis Carotídea/cirugía , Femenino , Lateralidad Funcional , Humanos , Masculino , Persona de Mediana Edad , Monitoreo Intraoperatorio/métodos , Examen Neurológico , Oxígeno/sangre , Curva ROC , Índice de Severidad de la Enfermedad , Espectroscopía Infrarroja Corta/métodos , Factores de TiempoRESUMEN
BACKGROUND AND PURPOSE: Although cerebral hyperperfusion after carotid endarterectomy (CEA) often impairs cognitive function, MRI does not always demonstrate structural brain damage associated with postoperative cognitive impairment. The purpose of the present study was to determine whether postoperative cortical neural loss, which can be detected by (123)I-iomazenil single-photon emission CT, is associated with cerebral hyperperfusion after CEA and whether it correlates with postoperative cognitive impairment. METHODS: In 60 patients undergoing CEA for ipsilateral internal carotid artery stenosis (>70%), cerebral blood flow was measured using N-isopropyl-p-[(123)I]-iodoamphetamine single-photon emission CT before and immediately after CEA and on the third postoperative day. The distribution of benzodiazepine receptor binding potential in the cerebral cortex was assessed using (123)I-iomazenil single-photon emission CT before and 1 month after surgery and was analyzed using 3-dimensional stereotactic surface projection. Neuropsychological testing was also performed preoperatively and at the first postoperative month. RESULTS: Post-CEA hyperperfusion and postoperative cognitive impairment were observed in 9 patients (15%) and 8 patients (13%), respectively. Post-CEA hyperperfusion was significantly associated with postoperative hemispheric reduction of benzodiazepine receptor binding potential (95% CIs, 2.765 to 148.804; P=0.0031). Post-CEA hyperperfusion (95% CIs, 1.183 to 229.447; P=0.0370) and postoperative hemispheric reduction of benzodiazepine receptor binding potential (95% CIs, 1.003 to 77.381; P=0.0496) were also significantly associated with postoperative cognitive impairment. CONCLUSIONS: Cerebral hyperperfusion after CEA results in postoperative cortical neural loss that correlates with postoperative cognitive impairment.
Asunto(s)
Corteza Cerebral/patología , Trastornos Cerebrovasculares/patología , Trastornos Cerebrovasculares/psicología , Trastornos del Conocimiento/patología , Trastornos del Conocimiento/psicología , Endarterectomía Carotidea , Neuronas/patología , Complicaciones Posoperatorias/patología , Complicaciones Posoperatorias/psicología , Adulto , Anciano , Análisis de Varianza , Estenosis Carotídea/cirugía , Corteza Cerebral/diagnóstico por imagen , Circulación Cerebrovascular , Trastornos Cerebrovasculares/diagnóstico por imagen , Trastornos del Conocimiento/diagnóstico por imagen , Femenino , Flumazenil/análogos & derivados , Humanos , Yofetamina , Masculino , Persona de Mediana Edad , Pruebas Neuropsicológicas , Complicaciones Posoperatorias/diagnóstico por imagen , Radiofármacos , Técnicas Estereotáxicas , Tomografía Computarizada de Emisión de Fotón Único , Tomografía Computarizada por Rayos XRESUMEN
PURPOSE: The aim of the present study was to determine whether preoperative cerebrovascular reactivity (CVR) to acetazolamide measured by quantitative brain perfusion single-photon emission computed tomography (SPECT) predicts development of cerebral ischemic lesions on postoperative diffusion-weighted magnetic resonance imaging (DWI) that are caused by microemboli during carotid endarterectomy (CEA). MATERIALS AND METHODS: One hundred and fifty patients with ipsilateral internal carotid artery stenosis (>70%) underwent CEA under transcranial Doppler monitoring of microembolic signals (MES) in the ipsilateral middle cerebral artery (MCA). Preoperative CVR to acetazolamide was measured using [(123)I]N-isopropyl-p-iodoamphetamine SPECT, and region of interest (ROI) analysis in the ipsilateral MCA territory was performed using a three-dimensional stereotaxic ROI template. DWI was performed within 3 days before and 24 h after surgery. RESULTS: Twenty-six patients (17.3%) developed new postoperative ischemic lesions on DWI. Logistic regression analysis demonstrated that, among the variables tested, a high number of MES during carotid dissection (95% CIs, 1.179 to 1.486; P < 0.0001) and preoperative reduced CVR to acetazolamide (95% CIs, 0.902 to 0.974; P = 0.0008), which were significantly associated with the development of new postoperative ischemic lesions on DWI. In 47 patients with MES during carotid dissection, the combination of number of MES during carotid dissection and CVR to acetazolamide identified development of new postoperative ischemic lesions on DWI with a positive predictive value of 100% or zero. CONCLUSIONS: Preoperative CVR to acetazolamide measured by quantitative brain perfusion SPECT predicts development of cerebral ischemic lesions on postoperative DWI that are caused by microemboli during CEA.
Asunto(s)
Acetazolamida/farmacología , Isquemia Encefálica/etiología , Encéfalo/diagnóstico por imagen , Circulación Cerebrovascular/efectos de los fármacos , Embolia/complicaciones , Embolia/etiología , Endarterectomía Carotidea/efectos adversos , Anciano , Anciano de 80 o más Años , Encéfalo/irrigación sanguínea , Encéfalo/efectos de los fármacos , Isquemia Encefálica/diagnóstico por imagen , Isquemia Encefálica/patología , Embolia/diagnóstico por imagen , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Tomografía Computarizada de Emisión de Fotón ÚnicoRESUMEN
BACKGROUND AND PURPOSE: Microemboli generated during dissection of the carotid arteries in patients undergoing carotid endarterectomy result in postoperative cerebral ischemic events. The purpose of this study was to determine whether these events correlate with middle cerebral artery blood flow velocity. METHODS: One hundred sixty-three patients with ipsilateral internal carotid artery stenosis (>70%) underwent carotid endarterectomy under transcranial Doppler monitoring of mean blood flow velocity and microembolic signals in the ipsilateral middle cerebral artery. RESULTS: Logistic regression analysis of several variables demonstrated that only middle cerebral artery mean blood flow velocity during carotid dissection was significantly associated with new postoperative neurological deficits in patients with microembolic signals during carotid dissection (95% CI, 1.069 to 1.528; P=0.0072). The combination of low middle cerebral artery mean blood flow velocity (
Asunto(s)
Velocidad del Flujo Sanguíneo , Isquemia Encefálica/etiología , Endarterectomía Carotidea/efectos adversos , Embolia Intracraneal/patología , Arteria Cerebral Media , Anciano , Anciano de 80 o más Años , Humanos , Embolia Intracraneal/complicaciones , Masculino , Persona de Mediana Edad , Arteria Cerebral Media/patología , Arteria Cerebral Media/fisiología , Ultrasonografía Doppler TranscranealRESUMEN
OBJECT: Cerebral hyperperfusion after carotid endarterectomy (CEA) impairs cognitive function and is often detected on cerebral blood flow (CBF) imaging. The purpose of the present study is to investigate structural brain damage seen on magnetic resonance (MR) images obtained in patients with cerebral hyperperfusion and cognitive impairment after CEA. METHODS: One hundred and fifty-eight patients with ipsilateral internal carotid artery stenosis (> or = 70%) underwent CEA. Neuropsychological testing was performed preoperatively and at the 1st postoperative month. Cerebral blood flow was measured using single-photon emission computed tomography before, immediately after, and 3 days after surgery. Magnetic resonance imaging was performed before and 1 day after surgery. In patients with post-CEA hyperperfusion (defined as a CBF increase > or = 100% compared with preoperative values) on CBF imaging, MR images were also obtained on the 3rd postoperative day, the day on which hyperperfusion syndrome developed, and 1 month after the operation. RESULTS: The incidence of postoperative cognitive impairment was significantly higher in patients with post-CEA hyperperfusion on CBF imaging (12 [75%] of 16 patients) than in those without (6 [4%] of 142 patients; p < 0.0001). Only 1 of 5 patients with cerebral hyperperfusion syndrome developed reversible brain edema in the cerebral hemisphere ipsilateral to the CEA on MR images obtained on the day hyperperfusion syndrome occurred. However, postoperative cognitive impairment developed in all 5 patients with cerebral hyperperfusion syndrome regardless of the presence or absence of new lesions on MR images. In addition, postoperative cognitive impairment developed in 5 (45%) of 11 patients with asymptomatic cerebral hyperperfusion on CBF imaging despite the absence of new lesions on any postoperative MR images. CONCLUSIONS: Although cerebral hyperperfusion syndrome after CEA sometimes results in reversible brain edema visible on MR imaging, postoperative cerebral hyperperfusion -- even when asymptomatic -- often results in impaired cognitive function without structural brain damage on MR imaging.
Asunto(s)
Estenosis Carotídea/cirugía , Circulación Cerebrovascular/fisiología , Trastornos del Conocimiento/etiología , Trastornos del Conocimiento/patología , Endarterectomía Carotidea/efectos adversos , Anciano , Estenosis Carotídea/patología , Estenosis Carotídea/fisiopatología , Trastornos del Conocimiento/fisiopatología , Estudios de Cohortes , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Pruebas Neuropsicológicas , Estudios Retrospectivos , Síndrome , Resultado del TratamientoRESUMEN
A 62-year-old man and a 44-year-old man with unilateral cervical carotid artery stenosis (less than 50% with echolucent plaque and ulceration) suffered recurrent ischemic stroke events despite treatment with antiplatelet and anticoagulation drugs. Carotid endarterectomy (CEA) was performed under transcranial Doppler monitoring for the detection of micro-emboli using a microscope inserted through a skin incision to minimize pressure on the carotid arteries. The atheroma plaque included an ulcer with fresh thrombi in both patients. Both patients awoke from anesthesia without new neurological deficits, and no ischemic stroke events have recurred since CEA. Endarterectomy is an effective method for preventing stroke in patients with severe carotid stenosis (>70%), but the efficacy of this procedure for mild carotid stenosis (<50%) remains uncertain, regardless of carotid plaque characteristics. The present cases suggest that even mild stenosis of the cervical carotid artery may result in ischemic stroke events that are refractory to medical treatment if the stenosis is associated with echolucent plaque with ulceration. Endarterectomy is recommended to prevent further stroke in such patients.
Asunto(s)
Isquemia Encefálica/cirugía , Arteria Carótida Común , Estenosis Carotídea/cirugía , Endarterectomía , Accidente Cerebrovascular/cirugía , Adulto , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/etiología , Estenosis Carotídea/complicaciones , Estenosis Carotídea/diagnóstico , Humanos , Masculino , Persona de Mediana Edad , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/etiologíaRESUMEN
BACKGROUND: Matrix metalloproteinase (MMP)-9 targets major components of the basal lamina of cerebral blood vessels and is a biochemical marker of blood-brain barrier disruption. The goal of this study was to determine whether plasma concentrations of MMP-9 in the jugular bulb during carotid endarterectomy (CEA) correlate with severity of intraoperative cerebral ischemia. METHODS: In 41 patients undergoing CEA for ipsilateral internal carotid artery (ICA) stenosis, plasma samples for measurement of MMP-9 concentration were intraoperatively obtained from a venous catheter inserted into the ipsilateral jugular bulb. Transcranial cerebral oxygen saturation using near-infrared spectroscopy was also monitored intraoperatively to assess the severity of the ischemic insult during ICA clamping. RESULTS: The MMP-9 concentrations were significantly higher after ICA declamping than before ICA clamping (p = 0.0023). A strong linear correlation was observed between the severity of the ischemic insult during carotid clamping and the increase in MMP-9 levels after ICA declamping (r = 0.776; p < 0.0001). At the postoperative neurological assessment, 3 patients showed transient minor neurological deficits. The MMP-9 level in the jugular bulb after ICA declamping was increased in patients with postoperative transient neurological deficits relative to those without. CONCLUSIONS: The concentration of MMP-9 in the jugular bulb during CEA correlates with the severity of intraoperative cerebral ischemia.
Asunto(s)
Endarterectomía Carotidea/efectos adversos , Complicaciones Intraoperatorias , Ataque Isquémico Transitorio/etiología , Venas Yugulares/enzimología , Metaloproteinasa 9 de la Matriz/sangre , Adulto , Anciano , Arteria Carótida Interna/cirugía , Estenosis Carotídea/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Oxígeno/sangre , Espectroscopía Infrarroja CortaRESUMEN
PURPOSE: Cerebral hyperperfusion after carotid endarterectomy (CEA) results in cerebral hyperperfusion syndrome and cognitive impairment. The goal of the present study was to clarify the clinical significance of postoperative crossed cerebellar hypoperfusion (CCH) in patients with cerebral hyperperfusion after CEA by assessing brain perfusion with single-photon emission computed tomography (SPECT). METHODS: Brain perfusion was quantitatively measured using SPECT and the [(123)I]N-isopropyl-p-iodoamphetamine-autoradiography method before and immediately after CEA and on the third postoperative day in 80 patients with ipsilateral internal carotid artery stenosis (>or=70%). Postoperative CCH was determined by differences between asymmetry of perfusion in bilateral cerebellar hemispheres before and after CEA. Neuropsychological testing was also performed preoperatively and at the first postoperative month. RESULTS: Eleven patients developed cerebral hyperperfusion (cerebral blood flow increase of >or=100% compared with preoperative values) on SPECT imaging performed immediately after CEA. In seven of these patients, CCH was observed on the third postoperative day. All three patients with hyperperfusion syndrome exhibited cerebral hyperperfusion and CCH on the third postoperative day and developed postoperative cognitive impairment. Of the eight patients with asymptomatic hyperperfusion, four exhibited CCH despite resolution of cerebral hyperperfusion on the third postoperative day, and three of these patients experienced postoperative cognitive impairment. In contrast, four patients without postoperative CCH did not experience postoperative cognitive impairment. CONCLUSIONS: The presence of postoperative CCH with concomitant cerebral hyperperfusion reflects the development of hyperperfusion syndrome. Further, the presence of postoperative CCH in patients with cerebral hyperperfusion following CEA suggests development of postoperative cognitive impairment, even when asymptomatic.
Asunto(s)
Endarterectomía Carotidea/efectos adversos , Isquemia/diagnóstico por imagen , Isquemia/etiología , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/etiología , Anciano , Encéfalo/irrigación sanguínea , Encéfalo/diagnóstico por imagen , Trastornos del Conocimiento/diagnóstico por imagen , Trastornos del Conocimiento/etiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Flujo Sanguíneo Regional , Tomografía Computarizada de Emisión de Fotón ÚnicoRESUMEN
A 75-year-old man, who had undergone coronary artery bypass graft and repair for abdominal aortic aneurysm, suffered from angina pectoris due to severe aortic valve stenosis complicated with asymptomatic bilateral cervical internal carotid artery stenoses. Brain perfusion imaging revealed reduced cerebral blood flow and cerebrovascular reactivity to acetazolamide in the bilateral cerebral hemispheres. First, the patient underwent left carotid endarterectomy, and the postoperative course was uneventful. Postoperative brain perfusion imaging showed improvement of cerebrovascular reactivity to acetazolamide in the bilateral cerebral hemispheres. Seven weeks later, the patient underwent aortic valve replacement, and his postoperative course was uneventful. Carotid endarterectomy rather than carotid artery stenting should be preceded for cervical carotid stenosis complicated with severe aortic valve stenosis.
Asunto(s)
Estenosis de la Válvula Aórtica/complicaciones , Estenosis Carotídea/cirugía , Endarterectomía Carotidea , Acetazolamida , Anciano , Estenosis de la Válvula Aórtica/cirugía , Estenosis Carotídea/diagnóstico , Prótesis Valvulares Cardíacas , Humanos , Imagen por Resonancia Magnética , MasculinoRESUMEN
BACKGROUND AND PURPOSE: The purpose of the present study was to determine whether preoperative cerebral hemodynamic impairment and reactive oxygen species produced during carotid endarterectomy (CEA) correlate with development of postoperative cerebral hyperperfusion. METHODS: Concentrations of malondialdehyde-modified low-density lipoprotein (MDA-LDL), a biochemical marker of oxidative damage, were measured in serum samples obtained from 90 patients undergoing CEA for ipsilateral ICA stenosis (>70%). Serum samples were obtained from a venous catheter inserted into the ipsilateral jugular bulb before clamping of the internal carotid artery (ICA), 10 minutes after clamping of the ICA, and 5 and 20 minutes after declamping of the ICA. Cerebral blood flow (CBF) and cerebrovascular reactivity (CVR) to acetazolamide were also measured using single-photon emission computed-tomography before CEA. In addition, CBF was measured postoperatively. RESULTS: Hyperperfusion (CBF increase >100% compared with preoperative values) was observed immediately after CEA in 12 patients (13%). Logistic regression analysis demonstrated that reduced preoperative CVR (95% CIs, 1.053 to 1.453; P=0.0097) and an increase in MDA-LDL (calculated as a percentage of the preclamp values) after ICA declamping (95% CIs, 0.862 to 0.980; P=0.0098) were significantly associated with development of postoperative cerebral hyperperfusion among the variables tested. Ten of 11 patients with reduced preoperative CVR and increased MDA-LDL after ICA declamping developed post-CEA hyperperfusion, and 2 of these patients developed cerebral hyperperfusion syndrome. CONCLUSIONS: Both preoperative cerebral hemodynamic impairment and reactive oxygen species produced during surgery correlate with development of cerebral hyperperfusion after CEA.
Asunto(s)
Estenosis Carotídea/cirugía , Circulación Cerebrovascular , Endarterectomía Carotidea/efectos adversos , Especies Reactivas de Oxígeno/metabolismo , Daño por Reperfusión/diagnóstico por imagen , Tomografía Computarizada de Emisión de Fotón Único , Adulto , Anciano , Isquemia Encefálica/diagnóstico por imagen , Isquemia Encefálica/metabolismo , Isquemia Encefálica/fisiopatología , Femenino , Humanos , Periodo Intraoperatorio , Lipoproteínas LDL/sangre , Modelos Logísticos , Masculino , Malondialdehído/sangre , Persona de Mediana Edad , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/metabolismo , Complicaciones Posoperatorias/fisiopatología , Cuidados Preoperatorios , Daño por Reperfusión/metabolismo , Daño por Reperfusión/fisiopatologíaRESUMEN
A 72-year-old man suffered blindness due to right central retinal artery occlusion. Cerebral angiography revealed tandem stenosis in the cervical, petrosal and cavernous portions of the right internal carotid artery (ICA). Blood flow from the vertebrobasilar artery via the right posterior communicating artery mainly perfused the right cerebral hemisphere. In addition, significant stenosis was observed in the left cervical carotid artery and the origin of the left vertebral artety. First, the patient underwent left carotid endarterectomy and vertebral artery to subclavian artery transposition. Two months later, ligation of the right ICA at its origin was performed. Postoperative course was uneventful and the patient has not experienced further ischemic events. We suggest that proximal ligation of the parent artery is a useful procedure for medically-refractory extradural ICA stenosis when surgical direct revascularization and percutaneous transluminal angioplasty cannot be performed.
Asunto(s)
Arteria Carótida Interna/cirugía , Estenosis Carotídea/cirugía , Duramadre/irrigación sanguínea , Ligadura/métodos , Procedimientos Quirúrgicos Vasculares/métodos , Anciano , Humanos , Masculino , Resultado del TratamientoRESUMEN
A 68-year-old man with left cervical internal carotid artery stenosis suffered crescendo transient ischemic attacks caused by mobile thrombus detected by carotid echography and secondary impairment of cerebral hemodynamic reserve demonstrated by positron emission tomography. Urgent carotid endarterectomy (CEA) was performed following pretreatment with edaravone and early clamping of the carotid arteries without intraluminal shunting. The postoperative course was uneventful, and postoperative magnetic resonance imaging and single-photon emission computed tomography revealed no new cerebral ischemic lesions and no findings of cerebral hyperperfusion, respectively. The risks associated with CEA are higher for patients with evolving stroke or crescendo transient ischemic attacks than that for patients with stable disease. This case demonstrates that urgent endarterectomy for cervical carotid artery stenosis with crescendo transient ischemic attacks caused by mobile thrombi and hemodynamic cerebral ischemia can be successfully performed following pretreatment with edaravone and early clamping of the carotid arteries.